MANUAL 


NEEVOUS  DISEASES 


kY 


A.  B.  AKNOLD,  M.  D. 


EMKrnTL'.S  PKOFEySOK  ON  Dl.SEA.SES  OF  THE  NeRVOIS  SysTEM,  CoL 

LEGE  OF  Physicians  and  Surgeons  of  Baltimore, 
President  of  the  Section  of  General 
Medicine,  Ninth  Interna- 
tional Medical 

Congress 


SECOND  EDITION  REVISED  AND  ENLARGED 


esi 


SAN    ERANCISCO 
THE    BANCROFT    COMPANY 

1  S 1)  0 

S2620 


c  €  e  •  •  . 


Entered  aecordiug  to  Act  of  Congress  in  the  year  1820,  by 

A.  B.  ARNOLD,  M.  D. 
In  the  office  of  the  Librarian  of  Congress,  at  Washington 


joo 


)77 


Preface 


TO  THE  SECOND  EDITION 


A    LTHOUGH  the  second  edition  of  this  Manual  has 

"[J    --^  -^     been  thoroughly  re-written  and  enlarged,  yet  the 

author  has  not  departed  from  his  original  design  to  give 

a  concise  description  of  the  essential  facts  in  relation  to 

^  the  study  and  treatment  of  nervous  diseases.    It  is  hoped 

jy  that  the   additions  to  the  preliminary  chapters  on  the 

anatomy  of  the  nervous  system  and  the  general  sympto- 

,    matoiogy  and  therapeutics  of  nervous  diseases  will  be 

V      found  acceptable.     Experience  in  teaching  has  induced 

^    the  author  to  adopt  the  arrangement  of  the  subject  matter 

followed  in  this  Manual. 

A.  B.  ARNOLD. 

San  Francisco,  1890. 


ILLUSTRATIONS. 


1.  Side  view  of  the  human  brain 5 

2.  Median  aspect  of  the  hemisphere          ....  7 

3.  Inferior  surface  of  the  brain 7  9 

4.  The  monkey  brain 11 

5.  Psycho-motor  centers 12 

6.  Topography  of  the  skull  (misplaced,  see  fig.  27)          .  219 

7.  Schema  of  the  cerebro-spinal  system  of  nerves       .         .  16 

8.  Vertico- transverse  section  of  the  brain          ...  18 

9.  Diagram  of  horizontal  section  of  brain    ....  19 

10.  Lateral  section  of  right  half  of  the  medulla         .         .  21 

11.  Diagram  of  the  chief  tracts  of  the  medulla     ...  22 

12.  Transverse  section  of  the  dorsal  spinal  cord        .         .  25 

13.  Diagram  illustrating  diffusion  of  the  electric  current     .  59 
14-20.     Motor  points .            63-06 

21.  Diagram  showing  position  of  elec;trodes           ...  70 

22.  Distribution  of  the  trigeminus 80 

24.  Normal  medullary  nerve  fibre 93 

25.  Alteration  of  nerve  fibre  after  section           ...  93 

26.  Diagram  of  reflex  paths  of  the  spinal  cord      .         .         .  145 

27.  Topography  of  the  skull 219 

28-29.     Attitudes  of  hands  and  fingers  in  athetosis      .         .  269 


CONTENTS. 


CHAPTER   I, 

Outlines   of  the   Anatomy   of  the   Nervous  System — The 

Motor  Cortical  Areas , 1 

CHAPTER   II. 

General  Symptomatology'  of  Diseases  of  the  Nervous  Sys- 
tem—  Sensory  Disturbances — Vaso-motor  Disturbances 
—  Motor  Disturbances  —  Cerebral  Symptoms  —  Spinal 
Symptoms 28 

CHAPTER  III. 

General  Therapeutics  of  Nervous  Diseases — Medical  Elec- 
tricity      49 

CHAPTER   IV. 

Diseases  of  the  Nervous  System — Neuralgia — Varieties  of 
Neuralgia — Neuritis — Neuromata 73 

CHAPTER   V. 

Varieties  of  Peripheral  Paralysis  —  Facial  Paralysis  — 
Isolated  Paralysis  of  the  Muscles  of  the  Neck,  Chest  and 
Back  —Isolated  Paralysis  of  the  Superior  and  Inferior 
Extremities — Lead  Paralysis — Arsenical  Paralysis — Diph- 
theric Paralysis — Reflex  Paralysis 97 

(V) 


vi  CONTENTS. 

CHAPTER  VI. 

PACK. 

Varieties  of  Local  Spasm — Convulsive  Tic — Spasm  of  the 
Muscles  of  the  Neck  and  Back — Spasm  of  the  Muscles  of 
the  Superior  and  Inferior  Extremities  (Writer's  Cramp)...  112 

CHAPTER   VII. 

3I1NOR  Neuroses  —  Headache — Hemicrania  —  Neurasthenia — 

Spinal  Irritation 122 

CHAPTER   VIII. 

Diseases  of  the  Membranes  of  the  Spinal  Cord — Pacchj'- 
meningitis  Spinalis — Pacchymeningitis  Cervicalis  Hyper- 
trophica-- Spinal  Meningitis-Spinal  Apoplexy-Thrombosis 
of  the  Sinuses 138 

CHAPTER   IX. 

Diseases  of  the  Spinal  Cord  —  Acute  and  Chronic  Myelitis 
—  Acute  Ascending  Paralysis— Hydromyel us  —  Syringo 
myelia  —  Unilateral  Lesion  of  the  Spinal  Cord  —  Con- 
cussion of  the  Spinal  Cord 144 

CHAPTER   X 

Systemic  Diseases  of  the  Spinal  CoRDr-Loco-motor  Ataxia 
— Friedrich's  Hereditary  Ataxia — Poliomyelitis  Anterior 
Acuta — Spastic  Spinal  Paralysis— Amyotrophic  Lateral 
Sclerosis — Progressive  Muscular  Atrophj- — Pseudo-Hyper- 
trophy of  Muscles— Bulbar  Paralysis 15 

CHAPTER   XL 

Diseases  of  the  Membranes  of  the  Brain  —  Hemorrhagic 
Pacchymeningitis— Tubercular  Meningitis— Meningitis  of 
the  Convexity 193 

CHAPTER   XII. 

Localization  of  Cerebral  Diseases — Aphasia— Topography 
of  the  Skull  in  relation  to  the  Convolutions 20G 


CONTENTS.  vil 

CHAPTER   XIII. 

^     PAGE. 

Diseases  of  the  Brain  —  Cerebral  Hyperjomia  —  Cerebral 
Anaemia — Cerebral  Heniorriiage — Hemiplegia  in  Child- 
hood—  Cerebral  Embolism  and  Thrombosis  —  Cerebral 
Tumor— Cerebral  Abscess— Cerebral  Syphilis 221 

CHAPTP]R   XIV. 

Multiple  Sclerosis  of  the  Brain  and  Spinal  Cord — Paral- 
ysis Agitans  —  Chorea  — Athetosis  —  Tetany  — Thomson's 
Disease 258 

CHAPTER   XV. 

Epilepsy — Meniere's  Disease — Hysteria — Hypochondriasis....  273 

CHAPTER   XVI. 

Paretic  Dementia  —  (General  Paresis  of  the  Insane) 299 

Bibliography 309 

Formul.t: 311 

Index 323 


CHAPTER  I. 

OUTLINES  OF  THE  ANATOMY  OF  THE 
NERVOUS  SYSTEM. 

In  the  following  Sketch  of  the  Anatomy  of  the  Nervous 
S3^stem  it  is  intended  to  give  prominence  to  those  parts 
that  are  of  special  importance  in  relation  to  Neuropa- 
thology. 


FISSURES    AND     CONVOLUTIONS     OF     THE     LATERAL    SURFACE 
OF    THE     HEMISPHERE. 

Each  hemisphere  is  marked  by  furrows  running  in  dif- 
ferent directions,  apparently  without  any  fixed  order,  but 
on  comparing  the  brains  of  the  higher  mammalia  fissures 
or  sulci  analogous  to  those  in  the  human  subject  are  rec- 
ognized that  follow  a  typical  arrangement.  Fissures 
divide  the  surface  of  the  hemisphere  into  convolutions, 
and  serve  to  mark  the  boundaries  of  the  cerebral  lobes. 

The  Fissure  of  Sylvius.  This  fissure  is  already  visible 
in  the  third  month  of  embryonic  life.  It  commences  on 
the  under  surface  of  the  hemisphere  and  divides  into  two 
branches — a  short  vertical  branch  and  a  long  horizontal 
branch.  The  bifurcation  of  the  two  branches  forms  a 
fossa,  which  lodges  the  island  of  Reil. 

(1) 


f  MA.\  CAL   OF  KEHVOCS   DISEASES. 

TJic  Central  Fissure  or  the  Fissure  of  Rolando.  This 
fissure  runs  in  nearly  a  vertical  direction  from  the  upper 
margin  of  the  hemisphere  toward  the  posterior  branch 
of  the  fissure  of  Sylvius. 

The  Parieto-Oceipital  Fissure.  The  lateral  portion  of 
this  fissure  is  short,  and  sometimes  not  recognizable.  Its 
median  portion  is  long  and  deep,  and  separates  the  parie- 
tal from  the  occipital  lobe. 

The  Interparietal  Fissure.  This  fissure  begins  at  a 
short  distance  behind  the  central  fissure,  and  runs  in  a 
horizontal  direction  toward  the  occipital  lobe. 

The  Paracentral  Fissure  runs  in  front  and  parallel  to 
the  central  fissure. 

The  Superior  and  Inferior  Frontal  Sulci  divide  the  con- 
volutions in  front  of  the  paracentral  fissure. 

The  termination  of  the  Calloso-Marginal  Fissure  is  repre- 
sented by  a  notch  in  the  superior  aspect  of  the  hemisphere 
between  the  central  and  interparietal  fissures. 

The  sidcus  occipitalis  transversus  and  longitudinalis 
inferior  divide  convolutions  on  the  lateral  aspect  of  the 
occipital  lobe. 

The  first  and  second  temporal  fissures  divide  the  respective 
coiwolutions  of  the  tempero-sphenoidal  lobe  on  the  lateral 
aspect  of  this  lobe. 

The  Frontal  Lobe  and  Its  Convolutions. 
The  frontal  lobe  is  bounded  on  its  superior  aspect  by 
the  longitudinal  fissure,  and  forms  the  frontal  extremity 
of  the  hemisphere.  Its  posterior  side  borders  on  the 
fissure  of  Rolando,  and  is  separated  inferiorly  from  the 
temporal  lobe  by  the  short  branch  of  the  Sylvian  fissure. 


OUTLINES  OF  ANATOMY.  S 

The  Ascending  Frontal  Convolution.  The  convolution 
running  upward  in  front  of  the  fissure  of  Rolando  and 
uniting  at  both  ends  with  the  convolution  at  the 
opposite  side  of  this  fissure  is  named  the  ascending  or 
anterior  frontal  convolution. 

The  First  or  Superior  Frontal  Convolution.  This  con- 
volution begins  at  the  upper  extremity  of  the  ascending 
frontal,  where  it  is  bounded  by  the  longitudinal  fissure. 
It  turns  downward  and  backward,  and  forms  a  part  of 
the  median  and  inferior  surface  of  the  hemisphere. 

The  Second  or  Middle  Fronted  Convolution.  This  con- 
volution is  separated  from  the  foregoing  by  the  superior 
frontal  fissure,  and  from  the  anterior  ascending  convolu- 
tion by  the  paracentral  fissure.  It  extends  forward  to 
the  extremity  of  the  frontal  lobe,  and,  bending  down- 
ward, forms  a  part  of  the  under  surface  of  the  hemisphere. 

The  Third  or  Inferior  Fronted  Convolution.  This  con- 
volution is  a  prolongation  of  the  lower  portion  of  the 
ascending  frontal.  It  winds  around  the  vertical  branch 
of  the  Sylvian  fissure,  and,  running  forward,  forms  the 
lateral  aspect  of  the  frontal  lobe.  The  last  three  frontal 
convolutions  constitute  the  so-called  prefrontcd  lobe. 


Convolutions  of  the  Parietal  Lobe. 

The  longitudinal  fissure  forms  the  upper  boundary  of 
the  parietal  lobe.  It  is  separated  from  the  frontal  lobe 
by  the  fissure  of  Rolando,  from  the  temporal  lobe  by  the 
fissure  of  Sylvius,  and  from  the  occipital  lobe  by  the 
parieto-occipital  fissure. 

The  Ascending  Parieted  or  Posterior  Central  Convolution 


4  MA  N  UA  L   OF  NER  V OUS  DIS EA  SES. 

borders  on  the  fissure  of  Rolando  and  runs  parallel 
with  the  oi^posite  ascending  frontal  convolution.  These 
two  convolutions,  which  form  the  RoJandic  region  of  the 
hemisphere,  are  also  spoken  of  as  the  Central  Convolutions. 

The  Upper  or  First  Parietal  Convolution  is  the  longitud- 
inal continuation  of  the  ascending  parietal,  and  has  the 
interparietal  fissure  for  its  inferior  boundary.  This 
convolution  consists  of  a  number  of  secondary  folds,  and 
is   often  mentioned  as  the  Parietal  Lobule. 

The  Second  Parietal  Convolution  is  situated  below  the 
interparietal  fissure.  That  portion  of  it  which  is  a 
continuation  of  the  ascending  parietal  curves  around 
the  end  of  the  posterior  branch  of  the  Sylvian  fissure, 
where  it  bends  downward  to  unite  with  the  temporal 
lobe.  This  portion  is  also  called  the  Supramarginal 
Convolution. 

A  fold  of  the  same  convolution,  which,  bordering  upon 
the  interparietal  fissure  below,  makes  an  angular  bend 
downward  and  then  runs  forward  to  unite  with  the  second 
temporal  convolution,  is  called  the  Angular  Gyrus. 


The  Temporal  Lobe. 

The  temporal  lobe  is  separated  by  the  fissure  of  Sylvius 
from  the  whole  of  the  frontal  lobe.  Its  inferior  portion 
fills  the  sphenoidal  fossa,  and  it  is  for  this  reason  often 
named  the  Tempero-Sphenoidal  Lobe, 

The  First  Temporal  Convolution  runs  parallel  with  the 
fissure  of  Sylvius.  Its  posterior  portion,  directly  below 
this  fissure,  is  contiimous  with  the  supramarginal 
convolution. 


OUTLINES  OF  ANATOMY. 


The    Second    Temporal   Convolution  is  a  continuation  of 
the  angular  gyrus,   and    unites    with  the  occipital    lobe. 


Fif4.   1. — Side  View  of  the  Human  Brain 
P. 


(EOKER.) 


F  Frontal  lobe. 

P  Parietal  lobe. 

0  Occipital  lobe. 

T  Temporal  lobe. 

S  Fissure  of  Sylvius. 

S'  Horizontal. 

S"  Ascending  branch. 

C  Central  fissure  (Fissure  of  Ro- 
lando.) 

A  Ascending  frontal  convolution- 

B  Ascending  parietal  convolution. 

F^,  F.,,  F.,  Superior,  middle,  infe" 
rior  frontal  convolution. 

/u  /■:■>  fi^  Superior,  inferior,  verti- 
cal frontal  fissure  (precen- 
tral  /;. 

Pi  Superior  parietal  convolution. 


Inferior   parietal    convolution 
(Gyrus  supramarginalis). 
P!  Gyrus  angularis. 
i-p  Interparietal  sulcus. 
cm    Extremity    of   the     Sulcus 
calloso  marginalis. 
Oi,    0.^,    O-i,   First,    second,    third 

Occipital  convolution. 
Po  Fissura  parieto-occipitalis. 
o  Transverse  occipital  fissure. 
o..  Sulcus   occipitalis  longitudi- 
nalis  inferior. 
Ti,    T.,,    T-i,   First,  second,  third 
temporal  convolution. 
^1,    tj.    First,    second   temporal 
fissure. 


The    Third    Temporal    Convolution    forms    the   inferio: 


6-  MA  X  UA  L   OF  NER  VOUS   DISEASES. 

portion  of  the  temporal  lobe.       Like  the  foregoing,  it  runs 
backward  and  connects  with  the  occipital  lobe. 

The    Occipital   Lobe. 

This  lobe  forms  the  posterior  part  of  the  hemisphere. 
It  is  separated  from  the  parietal  lobe  at  its  extremity  by 
the  parieto-occipital  fissure.  There  is  no  other  visible 
division  between  these  lobes  on  the  lateral  aspect  of  the 
hemisphere.  The  occipital  lobe  is  divided  by  short  and 
indistinct  folds,  which  radiate  upward  and  forward  where 
they  unite  with  the  parietal  and  temporal  convolutions. 

The  first  occipital  convolution  borders  above  on  the  lon- 
gitudinal fissure,  and  joins  the  superior  parietal  convo- 
lution. 

The  second  or  middle  ocrlpital  ronvolutinn  joins  the 
angular  gyrus. 

The  Third  or  Inferior  Occipital  Convolution  is  continu- 
ous with  the  third  temporal  convolution.  The  two  lower 
folds  of  the  Occipital  lobe  are  separated  by  the  trans- 
verse fissure  and  unite  at  the  extremity  of  the  lobe. 

Fissures  and  Convolutions  of  the  Median  Surface 
OF  THE  Hemisphere. 

Section  of  the  corpus  callosum  in  the  line  of  the  longi- 
tudinal fissure  exposes  the  median  surfaces  of  the  hemi- 
spheres. 

The  calloso-niaryinal  fissure  runs  parallel  with  the  cor- 
pus callosum.  It  incloses  a  part  of  the  way  the  gyrus  forni- 
catus.  This  convolution  begins  by  a  narrow  fold  beneath 
the  corpus  callosum,  curves  around  the  whole  length  of 
this  commissure,  unites  with  the  occipital  lobe  and  then 


OUT  LI  N  E  S   O  F  A  N  A  TO  M  Y .  7 

bending  downwards  and  forwards  it  forms  in  that  region 
the  gyms  hippocampi.  The  hook-like  extremity  of  this 
convolution  is  called  the  vncus  (unciatns  or  unciform 
process). 


Fifi 


Median  Aspeci'  of  the 


C,  C  Corpus  callosuni. 

G,  F  Gyrus  fornicatus. 

H  Gyrus  hippocampi. 

//    Sulcus  hippocampi. 

U  Gyrus  unciatus. 

C,  M  Sulcus  calloso-marginalis. 

F  Median  aspect  of  the  first 
frontal  convolution. 

C  P^xtremity  of  the  central  fissure. 

A  Frontal  and  B  posterior  cen- 
tral convolution.  (These 
inner  portions  of  the  central 
convolutions  constitute  the 
paracentral  lobule.) 


Hemi.sphkre.      (akjkr  EcivEK.  ) 
P    Precunial    convolution     (lobus 

quadra  tus). 
0,  Z  Cuneus. 

po  Parieto-occipital  tissure. 
0  Occipital  transverse  tissure. 
0,  C  Fissura  calcaria, 
O,  C,   Superior  and  0,  C,  inferior 

limb  of  tlie  calcarian  fissure. 
T^    Tiobulus     fusiformis.     (Gyrus 

occipito-temporalis. ) 
7  J  Lobulus  lingualis  (Gyrus  occi- 

pito-medialis. 


That  part  of  the  median  surface  of  the  hemisphere 
which  lies  above -the  fissura  calloso-marginalis,  corre- 
sponds with  the  superior  inner  portions  of  the  two  central 
convolutions,  and  is  called  the  paracentral  lobule. 


8  MA  X  UAL  0  F  NER  VOUS  D I  SEAS  ES . 

The  lobns  qnadraUis  or  precunial  convolution  is  that 
part  of  the  median  surface  of  the  hemisphere  which  is 
situated  between  the  ascending  portion  of  the  fissura 
calloso-marginalis  and  the  parieto-occipital  fissure. 

The  calcarian  fissure  begins  at  the  posterior  extremity 
of  the  occipital  lobe,  and  deeply  penetrates  it  in  a  vertico- 
transverse  direction.  Below  the  gyrus  fornicatusit  crosses 
the  parieto-occipital  fissure  at  an  acute  angle,  by  which 
a  triangular  portion  of  the  occipital  lobe  is  inclosed.  This 
part  of  the  lobe  is  called  the  cunevs  or  cuneiform  convolu- 
tion. 

The  lobuhts  limjualis  is  a  longitudinal  fold  on  the 
median  aspect  of  the  temporal  lobe.  It  unites  by  a  nar- 
row strip  with  the  gyrus  hippocampi. 

The  IoJ)ulus  fusiformis  is  separated  from  the  former  by  a 
curvelinear  fissure.  It  forms  the  inferior  border  of  the  tem- 
poral lobe,  and  runs  backwards  to  join  the  occipital  lobe. 

THE    INFERIOR    SURFACE    OF    THE    BRAIN. 

The  frontal  inferior  surface  of  the  hemisphere  consists 
of  portions  of  the  first,  second  and  third  convolutions. 
The  first  frontal  convolution  in  this  region  is  represented 
by  a  very  small  fold  called  the  gyrus  rectus.  It  is  sepa- 
rated from  the  under  surface  of  the  second  convolution  by 
the  olfactory  fissure.  The  sulcus  orhitalis  divides  the  latter 
from  the  inferior  portion  of  the  third  frontal  convolution, 
which  rests  on  the  orbital  plate.  It  curves  outward  and 
upward  and  forms  the  lateral  aspect  of  the  frontal  lobe. 

The  gyrus  hippocampi  forms  the  central  under-surface 
of  the  hemisphere.  A  part  of  this  region  is  also  occupied 
by  portions  of  the  lingualis  and  fusiform  lobules.  The 
rest  of  the  inferior  surface  of  the   hemisphere  behind  the 


OUTLINES  OF  ANATOMY.  9 

fissure  of  Sylvius   belongs  partly  to    the   temporal   and 
partly  to  the  occipital  lobes. 


Fig.  3. — Inferior  Surface  of  the  Hemisphere,   (after  Eoker.) 

t^    Sulcus     occipito-temporalis 
inferior. 
7\  inferior  and  T.^    middle    tem- 
poral fissure. 

po  Parieto-occipital  fissure. 

DC   Fissura  calcarina. 
H  Gyrus  hippocampi. 
U  riyrus  unciatus. 
Ch   Chiasm. 

C,  C  Corpora  candicantia. 
K,  K   Crus  cerebri. 
C  Corpus  callosum. 


F^  Gyrus  rectus. 

F.2  second  and  F3  third  frontal 
convohitions. 

Fi  Sulcus  olfactorius. 

F-^  Sulcus  orbitalis. 

T^  second  or  middle. 

7';j  Third  or  inferior  temporal  con- 
volution. 

7\  Lobulus  fusiformis  (Gyrus 
•     occipito  temperalis  lateralis.) 

7'j  Lobulus  lingualis  (Gyrus  occi- 
pito-temporalis medialis. 


The    Cortex. 
Histologists  distinguish  five  layers  of  nerve  cells  in  the 
cortex.     The  cells   are  of  different  shapes  and  sizes.     A 


10  MANUAL   OF  NERVOUS  DISEASES. 

large  number  of  them  consist  of  "  pyramidal."  or  "  giant 
cells;"  others  are  oval  or  irregular.  They  give  off 
"  branches"  that  connect  them  with  each  other.  A  fine 
connective  tissue,  called  the  neuroglia  surrounds  the  nerve 
elements  like  a  cement. 

Physiology  assigns  to  the  cortex  of  the  hemispheres  the 
seat  of  mental  activity.  The  following  considerations 
point  to  the  intimate  relation  existing  between  the  cortex 
and  the  manifestations  of  the  psychical  powers:  1.  Intel- 
lectual capacity  is  proportionate  to  the  development  of 
the  hemispheres.  This  is  shown  by  the  great  number  and 
complexity  of  tRe  convolutions  in  man,  which  enlarge  the 
area  of  the  cortical  substance.  2.  Smallness  or  atrophy 
of  the  hemispheres  is  observed  in  idiotism.  3.  Injury 
or  disease  of  the  hemispheres  gives  rise  to  cerebral  excite- 
ment, confusion  of  ideas,  stupor  and  coma. 


The  Excitable  Cortical  Areas. 
In  speaking  of  the  "  localization  of  the  functions  of  the 
brain"  it  must  be  understood  that  in  our  present  state  of 
knowledge,  this  term  mainly  refers  to  the  results  of  the 
highly  interesting  experiments  of  Fritsch,  Hitzig,  Ferrier 
and  their  followers.  When  according  to  these  experi- 
ments certain  limited  areas  of  the  cortex  of  the  brain  are 
excited  Vjy  the  electric  current,  uniform  movements  are 
made  V>y  the  animal;  and  conversely,  when  such  areas 
are  extirpated,  these  movements  cannot  be  evoked,  at 
least  for  a  considerable  length  of  time  afterwards.  Tlius, 
the  animal  moves  a  foreleg,  a  hindleg,  or  the  eye,  when- 
ever the  electric  stimulus  excites  a  definite   cortical  area. 


OUTLINES  OF  ANATOMY.  11 

Ferrier  experimented  on  the  monkey.  The  accompanying 
figure  gives  the  topography  of  the  surface  of  a  monkey 
brain  of  an  inferior  species. 


r 


/ 


Oh 


5 

Fig.  4.— The  Monkey  Braix.     (Meynert.) 
(Cerocebus  cinomolgus.) 

1  Inferior    extremity   of  the         C  Central  fissure   (Fissure  of 

forehead.  Rolando). 

2  Inferior  extremity    of  the       F^  Inferior  frontal  fissure. 

occiput.  F.,  Superior  frontal  fissure. 

3  Inferior   extremity   of    the      PC  Paracentral  fissure. 

temple.  IP  Interparietal  fissure. 

4  Cerebellum.  PF  Parallel  fissure. 

5  Medulla  oblongata.  EF  External     occipital    fissure 
FS  Fissure  of  Sylvius.  (monkey  fissure). 

AB  Posterior,  or  ascending  OL  Occipital  lobe, 
branch. 
Ferrier  mapped  the  cortex  of  the  human  brain  into 
areas  that  correspond  with  the  excitable  areas  of  the 
monkey  brain.  From  his  figures  it  appears  that  the 
principal  '  motor  zone"  is  located  in  the  region  of  the 
central  convolutions  (Rolandic  region).  It  is  a  significant 
fact  that  cells  of  a  large  size,  resembling  those  of  the 
anterior  cornua  of  the  spinal  cord  abound,  in  that  region. 
Sufficient  pathological  evidence  has  now  accumulated  in 
support  of  the  existence  of  excitable  motor  areas  in  the 
regions  indicated  by  the  experiments. 


if  MA  N  UA  L   OF  XER  VOUS  D  IS  EA  S  ES . 

PsYCHo-iMoTOR  Centers. 


Fig.  5. — Side  and  Upper  View  of  the    Brain  of  Man. 
[According  to  Ferrier.) 

1  On  the  posterior  parietal  (posterior  parietal  lobe).  Advance 
of  the  opposite  hind  limb,  as  in  walking. 

2,  3,  4  Around  the  upper  extremity  of  the  Fissure  of  Rolando. 
Complex  movements  of  the  opposite  leg  and  arm  and 
of  the  trunk,  as  in  swimming. 

a,b,c,d  On  the  posterior  parietal  (posterior  central  con vohition). 
Individual  and  combined  movements  of  the  lingers 
and  wrist  of  the  opposite  hand.  Prehensile  move- 
ments. 

5  At  the  posterior  extremity  of  the  superior  frontal  convolu- 

tion.    Extension   forward  of    the   opposite  arm   and 
hand. 

6  On  the  upper  part  of  the  antero  parietal  or  ascending  frontal 

convolution  (anterior  central).  Supination  and  flexion 
of  the  opposite  forearm. 

7  On  the  median  portion  of  the  same  convolution.     Retraction 

and  elevation  of  the  opposite  angle  of  the  mouth  by 
meaus  of  the  zygomatic  muscles. 


OUTLINES   OF  AN  ATOMY.  13 

8  Lower  down  on  the  same  convolution.  Elevation  of  the  ala 
nasiand  upper  lip. 

9,  10  At  the  inferior  extremity  of  the  same  convolution.  Opening 
of  the  mouth  with  protrusion  (9)  and  (10)  retraction 
of  the  tongue.     Region  of  Aphasia.     Bilateral  action. 

11  Between  (10)  and  fll)  and  the  inferior  extremity  of  the  pos- 

terio-parietal  convolution.  Retraction  of  the  opposite 
angle  of  the  mouth  ;  the  head  turned  slightly  to  one 
side. 

12  On  the  posterior  portion  of  the  superior  and  middle  frontal 

convolution.  The  eyes  open  widely,  the  pupils  dilate, 
and  the  head  and  eyes  are  turned  toward  the  opposite 
side. 

13,  13'  On  the  supra-marginal  lobule  and  angular  gyrus.  The 
eyes  move  toward  the  opposite  side  with  an  upward 
(13)  or  downward  (13')  deviation.  The  pupils  generally 
contracted.     Center  of  vision. 

14  On  the  infra-marginal  or  superior  (first)  tempero-sphenoidal 
convolution.  Pricking  of  the  opposite  ear;  the  head 
and  eyes  turn  to  the  opposite  side  and  the  pupils 
dilate  largely.     Center  of  hearing. 

Theories  of  the  Motor  Phenomena. 

It  should  be  premised  in  connection  with  the  theories 
explanatory  of  the  phenomena  observed  in  the  experi- 
ments, that  the  intervention  of  the  cortical  substance  is 
not  necessary,  as  the  movements  also  occur  when  the 
excitable  areas  are  denuded  of  their  gray  covering.  The 
latter  serves  as  the  medium  of  voluntary  impulses.  The 
question  arises:  What  is  the  nature  of  the  functional 
defect,  when,  on  the  extirpation  of  certain  circumscribed 
areas  of  the  cortex,  the  movements  cease  to  be  elicited  by 
the  electric  stimulation. 

Hitzig  attributes  the  defect  to  the  loss  of  the  muscular 
sense:  the  animal  being  inconsequence  unable  to  co-ordi- 
nate the  movements  of  corresponding  groups  of  muscles. 


U  MA  NUA  L   O  F  NEB  VO  US  D  ISEA  SES . 

Ferrier  ascribes  the  defect  to  a  psychical  inability  to 
initiate  voluntary  movements. 

According  to  Munk,  there  is  an  incapacity  to  recall  the 
representations  of  co-ordinate  movements  ^Yhich  the 
animal  had  learned  by  experience. 

It  may  be  of  interest  to  summarize  the  conclusions 
which  Munk  has  drawn  from  his  numerous  and  well-con- 
ducted experiments.  He  localizes  the  excitable  areas  of 
the  cortex  as  follows: 

1.  The  region  of  the  leg.  The  upper  third  of  the  cen- 
tral convolutions  and  the  upper  adjacent  portion  of  the 
parietal  lobule. 

2.  The  region  of  the  arm.  The  middle  third  of  the 
central  convolutions  and  lower  portion  of  the  parietal 
lobule. 

3.  The  region  of  the  head.  The  lower  third  of  the  cen- 
tral convolutions  and  a  contiguous  portion  of  the  frontal 
convolution  bordering  on  the  fissure  of  Sylvius. 

4.  The  center  of  vision.  The  surface  of  the  occipital 
lobe. 

5.  The  center  of  hearing.     The  temporal  lobe. 

6.  The  ocular  region.     The  gyrus  angularis. 

7.  The  region  of  the  ear.      The  marginal  convolution. 

8.  The  region  of  the  nape  of  the  nech.  The  part  of  the 
frontal  lobe  adjacent  to  the  middle  third  of  the  frontal 
ascending  convolution. 

9.  The  region  af  the  trunk.  The  convex  surface  of  the 
frontal  lobe  bordering  on  the  precentral  fissure. 

The  results  of  the  recent  investigations  of  Luciani, 
Horsley  and  Shaefer  agree  in  the  main  with  those  of 
]\[unk. 

Ferrier,    since   the   first   publication  of  his  celebrated 


0  U  TL INES  OF  ANATOMY.  15 

experiments,  has  somewhat  modified  his  views  in  regard 
to  the  so-called  psycho-motor  centers.  There  is  now  a 
tendency  among  neurologists  to  consider  the  excitable 
cortical  areas  in  the  light  of  sensory-motor  centers  as  will 
be  inferred  from  the  following  summary  of  Munk's  late 
contributions.  To  the  cortical  zone  of  the  Rolandic  region 
he  assigns  the  function  of  elaborating  perceptive  images  of 
the  tactile  and  muscular  sensations,  that  are  constantly 
conveyed  to  the  intelligence.  The  feelings  attending  the 
action  of  muscles,  tendons  and  ligaments  in  voluntary 
and  reflex  movements  are  registered  in  memory  as  repre- 
sentatives of  special  movements.  When  these  mnemonic 
images,  which  consist  of  components  of  the  registered 
sensations  are  destroyed  by  the  method  of  extirpation, 
the  corresponding  movements  can  no  longer  be  innervated 
by  voluntary  impulse  or  artificially  excited.  Decortation 
of  the  visual  center  produces  "  psychical  blindness."  The 
animal  sees  perfectly  well,  and  avoids  objects  that  are  put 
in  his  way,  but  does  not  recognize  the  food  set  before 
him.  He  has  lost  the  power  of  associating  the  perception 
of  the  food  with  the  object  of  his  sight.  When  the  audi- 
tory center  is  destroyed  the  animal  is  unable  to  recall 
auditory  images  although  he  hears  the  sounds  well 
enough.  This  is  "psychical  deafness."  The  animal  does 
not  recognize  the  voice  of  his  master,  although  it  hears 
the  sounds. 

Systems  of  Nerve-Fibres  of  the  Brain. 

Three   main  divisions  of  nerve  fibres  may  be   distin- 
guished in  the  white  substance  of  the  brain. 

1.  The  association  system  of  fibres  connect  contiguous 
and  remote  convolutions  of  the  hemisphere.  They  are 
arched,  and  present  their  concave  side  to  the  surface  of 
the  brain. 


16 


MANUAL   OF  NERVOUS  DISEASES. 


2.  The  commissural  system  of  fibres  connect  symmet- 
rical parts  of  the  hemispheres.  They  present  in  their 
course  the  shape  of  the  letter  U.  These  fibres  constitute 
the  corpus  calossum. 


Fig.  7.     Schema    of    the   Cerekro-Spinal   System    of    Nerves. 
(Landois.) 


0  U  TL INES  OF  A  KA  T  (J  M  Y , 


17 


The  pyramidal  tract. 

Fibres  connecting  the  cor- 
pus quadrigemina  and 
tegementiim. 

Their  further  course. 

Fibres  connecting  tlie  cor- 
pus striatum  and  lenti- 
cular nucleus  ^vith  the 
crusta. 

Their  further  course. 

Course  of  sensory  fibres. 

Transverse  section  of  th 
spinal  cord. 

Anterior  and  r,  W,  pos- 
terior roots  of  nerves. 

Associating  fibres. 

Co:niidssuial  fibres. 


?).  The  system  of  radiating  fibres  (corona  radiata,  pedun- 
cular fibres).  These  nerve  fibres  come  from  the  hemi- 
spheres, and  converge  at  the  base  of  the  brain,  where  they 
go  to  form  the  internal  capsule. 


c,  c 

Cortex  of  the  brain. 

5,  5 

Cs 

Corpus  striatum. 

6,  6 

NL 

Lenticular  nucleus. 

TO 

Optic  thalamus. 

V 

Corpora  quadrigemina. 

m 

P 

Crura  cerebri. 

8,  8 

H 

Tegementum. 

P 

Crusta. 

1,1 

Eadiate  fibres  of  the  cor- 

pus striatum. 

m 

2,2 

Those  of    the    lenticular 

S,  S 

nucleus. 

R 

3,3 

Those  of  the  optic  thala- 

mus. 

\,\ 

4,  4 

Those  of  the  corpora  quad- 

rigemina and  tegemen- 

a, a 

tum. 

c,  c 

The  Internal  Capsule. 
The  connection  of  the  medullary  substance  of  the 
hemisphere  with  the  deep-seated  parts  of  the  brain,  and 
finally  with  the  spinal  cord,  is  effected  by  the  conver- 
gence of  parts  of  its  constituent  fibres  toward  the  large 
ganglia  at  the  base  of  the  brain,  where  they  present  a 
white  strand  of  fibres  called  the  internal  capsule.  That 
part  of  the  capsule  in  front  of  the  head  of  the  caudate 
nucleus  and  behind  the  lenticular  nucleus,  constitutes 
the  anterior  limb  of  the  internal  capsule.  As  the  cap- 
sule passes  along  the  internal  margin  of  the  lenticular 
nucleus,  it  makes  a  bend  (genu)  and   runs  between  the 


18 


M  A  X U A  L   0 F  X E R  \ ' 0  6^9   DISE A  S E S 


front  of  the  optic  thalamus  and  behind  the  lenticuhir 
nucleus,  where  it  forms  the  posterior  limb  of  the  internal 
capsule.  The  continuation  of  the  tract  of  fibres  of  which 
the  capsule  consists,  forms  part  of  the  peduncle  of  the 
brain;  and  passing  on  through  the  pons,  and  then  to  the 
medulla  oblongata,  it  decussates  in  the  anterior  pyra- 
mids, from  which  circumstance  it  has  been  named  the 
pyramidal  tract.  The  fibres  of  this  tract  chiefly  come  from 
the  two  central  convolutions,  the  paracentral  lobule  and 
the  supra-marginal  gyrus.  In  its  dow^nward  course  it 
forms  a  distinct  fasciculus  of  the  cord,  nnd  disappears 
after  having  connected  wdth  the  successive  motor  cells  in 
different  regions  of  the  cord. 


Claustrum 


Len<icirai  y 
Nucleu'^ 
Horn  of  \^n^v^ 


(  laustruin 


Sphenoidal   Horn    of 
Lat.  Ventricle 
Post-cerebral  Arteries 


8.  — Vertic'o-transvekse  Section  of  the  Brain,  Posterior  to 
THE  Tlbercu'la  Mammillari.a,  Antkhor  to  the 
Peduncle.     (Charcot.) 


OUTL  /.V  ES   0  F  A  NA  TO  M  Y. 


19 


On  comparing  the  number  of  fibres  that  come  from  the 
hemisphere  and  pass  to  the  internal  capsule,  with  the 
small  size  of  the  cms  cerebri,  the  difference  in  mass  is 


Fig. 


9. — Diagram  of  a  Horizontal  Section  of  the  Brain  Below 
THE  Level  of  the  Cokpus  Callosum.     (Wernike.) 


/  Island  of  Reil. 

t  h    Thalamus  optici. 

n  I    Lenticular  nucleus. 

n  c    Head  of  the  caudate  nucleus. 

N  c'    Extremity    of   the    caudate 

nucleus. 
C  I    Anterior  limb  of  the  internal 

capsule. 
<7  /■ '    Posterior  limb  of  the  internal 

capsule. 

apparent.  Some  of  those  fibres  in  their  passage  down- 
wards must  therefore  be  interrupted,  or  lost  in  parts 
at  the  base  of  the  brain.     A  portion  of  the  fibres  occupy- 


G,  f  Gyrus  fornicatus. 

S  P    Anterior  horn  of  the  lateral 

ventricle. 
T  Corpus  Calossum. 
E  C  External  capsule. 
(7  I  Claustrum. 
V  Ventricle. 
G  h  Gyrus  hii^pocampi. 


so  MAXUAL   OF  NERVOUS  DISEASES. 

ing  the  anterior  limb  of  the  internal  capsule  enter  the 
corpus  striatum.  This  basal  ganglia,  the  optic  thalamus 
and  the  corpora  quadrigemina  may  be  considered  as 
"intermediary  stations"  where  the  entering  nerve  fibres, 
and  those  that  proceed  from  them  are  modified  in  their 
function.  The  exact  functions  of  these  basal  ganglia  are 
however  not  well  understood.  The  rest  of  the  fibers  of 
the  anterior  limb  of  the  interior  capsule  constitute  the 
pyramidal  tract.  It  occupies  the  middle  third  of  the 
foot  of  the  crus  cerebri.  The  outer  third  of  the  crus  is 
composed  of  fibres  that  come  from  the  corpus  striatum, 
and  its  inner  third  consists  of  fibres  that  pass  to  the 
optic  thalamus,  the  corpora  quadrigemina  and  posterior 
part  of  the  hemisphere. 

According  to  the  investigations  of  Meynert,  there  is  an 
anatomical  distinction  between  the  inferior  part  of  the 
crus  cerebri,  which  he  calls  the  crusta,  and  its  upper 
part  the  tegementum.  The  fibres  of  the  crusta  consist  of 
the  pyramidal  tract,  and  those  of  the  tegementum  con- 
sist of  fibres  that  come  from  the  spinal  cord  and  pass  to 
the  mesocephalon. 

Nerve-tracts  of  the  Cerebellum. 
The  connection  of  the  cerebellum  with  adjoining  parts 
consists  of  fasciculi  of  afferent  and  efiferent  nerves  that 
form  the  three  peduncles  of  that  organ.  Although  little 
has  been  accurately  determined  in  regard  to  the  fmictions 
of  the  cerebellum,  its  influence  on  the  cerebrum,  the 
spinal  cord  and  intermediate  nervous  structures  must  be 
considerable  as  shown  by  the  numerous  nerve  paths  that 
connect  it  with  these  parts. 


0  U  TL  IKES  OF  AKATO  M  Y. 


21 


Nerve-nuclei    and    Nerve-fibres    of    the   Medulla. 

The    components    of   the    complex    structure   -of    the 

medulla  oblongata  that  merit  particular  attention,  include 


PyKr 


Fk;.  10. — Lateral   View  or   the 

SEEN    FROM   THE    SURFACE   OF  ': 

Py  Pyramidal  tract, 
Py,  Kr    Decussation  of     pyra- 
mids. 
O  Olivarj'  body. 
Os  Superior  olivary  body. 

5  Motor, 

5'  Middle  sensory, 
5"  Inferior   sensory     nucleus 
of  the  trigeminus. 

6  Nucleus  of  abducens. 
G  f  Genu  facialis. 

7  Nucleus  facialis. 


Right  Half  of   the   Medulla, 
'HE  Section.     (After  Erb.) 

8  Posterior   median    acoustic 

nucleus. 

9  Glos.^o  pharyngeal  nucleus. 

10  Nucleus  of  vagus. 

11  Spinal   accessory  nucleus. 

12  Hypoglossal  nucleus 

Kz     Nucleus    of    the    funiculis 

gracilis. 
R5  Trigeminus  roots,    these  of 

the  Re  Abducens  and  R^ 

Facialis. 


2^2 


MA  N  U  AL  OF  N  E  li  VOU  S  DI  SEA  S  E  S . 


the  collections  of  gray  masses  from  which  the  roots  of 
some  of  the  cranial   nerves  on  the   floor  of  the  fourth 


Fig.  11. — Diagram  of 


01  Olivary  body. 

V  Anterior, 

S  Lateral  andH  Posterior  spinal 
funiculi. 

a  Pyramido-anterior  tract. 

d  Pyramido-lateral  tract. 

Py  Pyramidal  tract. 

b  Remainder  of  anterior  col- 
umn. 

c  Remainder  of  lateral  column. 

e,  e  Cerebello-lateraltract. 


S          H 

THE  Chief  Tbacts  of  the  Medulla. 
(After  Erb.) 

g   Funiculus   cuneatus,  and 


g 


f     Funiculis    gracilis,    and 
nucleus  of  the  same. 


nucleus  of  the  same. 
P,  c  i     Internal     fasciculus    of 

the  peduncle  cerebelli. 
P,   c,   e  external   fasciculus    of 

the  same. 
Cq,  F   Tract  from  corpus  quad. 

to  formato  retic. 
Cq,    O    The     same    to    olivary 

body. 
Thl     tract  from   the   tlialamus 

opticus.      The     formatis 
f  reticularis     is    piesented 

by  shading  in   the  center 

of  the  figure. 


0  UTL 1  NES   OF  A  NA  TOM  Y.  23 

ventricle  arise,  and  also  tlie  different  nerve  tracts  in  their 
relationship  to  the  spinal  cord.  The  annexed  diagrams 
are  intended  to  show  the  positions  of  the  nuclei  and 
tracts. 


Cerebro-Spixal  Conducting  Paths. 
At  the  lower  end  of  the  medulla,  the  larger  portion  of 
the  pyramidal  tract  crosses  and  enters  the  lateral  col- 
umns of  the  spinal  cord.  This  part  of  the  tract  is  called 
the  crossed  pyramidal  tract.  A  small  portion  which  does 
not  cross  borders  upon  the  anterior  fissure  of  the  cord, 
and  is  called  ^/?e  direct  pyramidal  tract  (Tiirk's  column). 
Both  the  crossed  and  the  direct  pyramidal  tracts  undergo 
secondary  descending  degeneration  in  lesions,  affecting 
the  internal  capsule.  The  direct  cerebellar  tract  consists 
of  fibres  at  the  periphery  of  the  lateral  column.  In  its 
upward  passage  it  lies  on  the  surface  of  the  restiform 
l)ody  and  enters  the  inferior  peduncle  of  the  cerebellum. 
This  cerebello-spinal  conducting  path  is  subject  to  second- 
ary ascending  degeneration.  GolVs  column  borders  upon 
the  median  fissure  of  the  posterior  spinal  column.  In 
passing  upwards  from  the  lumbar  region  of  the  cord  it 
enters  the  medulla  and  connects  by  arcuate  fibres  with  the 
inferior  peduncle  of  the  cerebellum.  Loss  of  sensibility  has 
not  been  noticed  in  disease  of  GoU's  column.  The  outer 
portion  of  the  posterior  column  of  the  spinal  cord  is  known 
as  Burdach^s  column.  It  consists  of  fibres  that  enter  the 
cord  by  the  posterior  nerve  roots.  This  column  con- 
tains a  sensory  conducting  tract,  and  joins  the  fibres 
which  constitute  the  posterior  third  of  the  hinder  limb  of 


f^      MA  X CA  L   OF  XEB  VO  US  DIS EA  SES . 

the  internal  capsule..  This  region  of  the  capsule  is  in 
the  immediate  vicinity  of  what  is  called  the  ''  sensory 
crossway,"  where  fibres  of  special  and  common  sensation 
meet.  For  the  more  precise  information  in  regard  to 
some  of  these  distinct  nerve  paths,  we  are  indebted  to  the 
admit  able  investigations  of  Flechsig.  Tiirk  had  previously 
made  the  observation  that  lesions  affecting  certain  parts 
of  the  brain  stood  in  relation  to  secondary  degeneration 
of  definite  tracts  of  nerve  fibres.  Flechsig  subsequently 
discovered  that  these  and  other  bundles  of  nerve  fibres 
in  the  brain  and  spinal  cord  acquire  their  medullary 
sheaths  at  different  stages  of  embryonic  development. 
By  this  method  of  research  he  succeeded  in  determining 
the  existence  of  distinct  cerebro-spinal  tracts  of  nerve 
fibres. 

Additional  structural  peculiarities  of  the  spinal  cord 
remain  to  be  mentioned.  The  regions  of  the  antero- 
lateral depression  of  the  cord  where  the  anterior  nerve 
roots  are  situated  are  called  the  anterior  root  zones.  The 
posterior  root  zones  are  in  the  regions  of  the  posterio- 
lateral  groove  of  the  cord  where  the  posterior  nerve  roots 
originate.  The  gray  matter  at  the  tips  of  the  posterior 
cornua  is  called  the  gelatinous  substance  of  Rolando.  Near 
and  along  the  junction  of  the  anterior  and  posterior 
cornua  a  peculiar  vesicular  appearance  of  the  central  gray 
substance  of  the  cord  is  observed  which  bears  the  name 


0  U  T  L  IXES   0  F  A  NA  TO  MY.  2t 

of  Clarl-e^s  column.     The  format io  reticularis  is  an  inter- 
lacement of  fibres  between  the  anterior  root  zones. 


Fig.  12.     Transverse  Section  of  the 
Half  of  the  Dorsal  Region. 

C,       Anterior  commissure.  G, 

d  c'    Filjres   which  pass    from       a  r, 
the    vesicular    column 
of  Clarke  (v  c)  to  the      a  r', 
direct  cerebellar  tract. 

a,       Anterior  grey  horn. 

P,      Posterior  grey  horn. 

P  t,   Pyramidal  tract  of  the  lat 
eral  column. 

T,       Column  of  Tlirk. 

d  c,    Direct  cerebellar  tract. 


V  c, 
f  r, 

pr, 


Spinal  Cord  in  the  Upper 
(After  Flechsig.) 
GoU's  column. 
Internal    portion   of    the 

Anterior  root-zone. 
External   portion  of    the 

Anterior  root-zone. 
Columns  of  Clarke. 
Reticular  formation  of  the 
spinal  cord. 
Burdach's  column, 
p  r",  Posterior  root  zones 


Spinal  Ganglion  Cells 
Nerve  cells  varying  in  size  and  number  occupy  differ- 
ent regions  of  the  central  gray  matter  of  the  spinal  cord. 
They  are  especially  numerous  in  the  cervical  and  lumbar 


S6  M  A  X U A  L   0 F  XERVO  U S   D I S E A  S E S . 

segments.  Groups  of  very  large  cells  are  found  in  the 
anterior  cornua.  Cells  of  smaller  size  and  less  in  number 
are  found  in  the  gelatinous  substance  and  the  posterior 
nerves.  Clarke's  column  contains  but  few  cellular  ele- 
ments. All  the  cells  in  the  cord  are  surrounded  by  a  line 
network  of  nerve  fibres  and  interstitial  tissue  (neuroglia). 
The  spinal  ganglion  cells  perform  the  function  of  motor, 
sensory  and  reflex  centers.  There  is  also  strong  evidence 
that  the  cells  of  the  anterior  nerves  exert  a  trophic  influ- 
ence on  the  muscular  organs  with  which  they  are  con- 
nected. 

Sensory  Conducting  Paths  of  the  Spinal  Cord. 

Our  knowledge  in  regard  to  distinct  sensory  tracts  in 
the  cord  is  still  very  imperfect.  We  only  know  that  all 
sensory  impressions  enter  the  posterior  nerve  roots  and 
are  transmitted  to  the  posterior  cornua.  The  sensory 
fibres  of  the  cord  on  their  entrance  immediately  cross 
over  to  the  opposite  side. 

Circulation  of  the  Brain. 
It  is  of  pathological  importance  to  consider  briefly  the 
peculiarities  of  the  cerebral  circulation.  The  brain 
receives  its  blood  from  two  sources — from  the  verte- 
bral arteries  and  the  internal  carotids.  Each  carotid 
divides  into  two  large  branches — the  anterior  cerebral  and 
the  middle  cerebral  arteries.  It  is  the  distribution  of  the 
latter  which  is  of  special  interest.  This  artery  enters  the 
fissure  of  Sylvius  and  sends  branches  to  the  lenticular 
nucleus  and  adjacent  parts  of  the  brain,  including  por- 
tions of  the  caudate  body  of  the  corpus  striatum,  the 
optic  thalamus  and  the  internal  capsule.  Some  of  the 
branches  are  also  distributed  to   the  greater  part  of  the 


O  U TL  rXES  0  F  A  XA  TO  M  Y .  27 

central  convolutions,  the  supranmrginal  and  angular  con- 
volutions, and  partly  to  the  inferior  frontal  convolution. 
Although  the  middle  and  anterior  cerebral  arteries  have  a 
common  origin,  yet  their  ramifications  do  not  freely 
anastomose.  They  are  terminal  arteries.  It  is  due  to 
this  circumstance  that  in  occlusion  of  branches  of  the 
middle  cerebral  artery,  collateral  circulation  often  fails  to 
be  established.  Hemorrhage  in  the  lenticular  fascular 
district  is  verv  common. 


CHAPTER    IT. 

OEXERAL    SYMPTOMATOLOGY    OF   DISEASES 
OF  THE  XERYOUS  SYSTEM. 

SENSORY    DISTURBANCES. 

1.  Hyperalgia.  Pain  is  the  most  common  of  all  the 
varieties  of  morbid  sensibility.  The  mind  locates  the 
seat  of  pain  with  great  precision,  when  the  source  of  irri- 
tation affects  an  external  part  of  the  body,  but  often  fails 
to  do  so  when  internal  parenchymatous  organs  are 
involved.  It  is  well  known  that  extensive  and  destruct- 
ive disease  of  the  brain,  lung  and  liver  does  not  give  rise 
to  pain  if  the  enveloping  membranes  of  these  structures 
are  not  implicated.  The  character  of  the  pain  is  often 
significant  of  the  part  which  is  affected.  For  example, 
neuralgic  pain  is  paroxysmal,  lancinating,  darting,  etc. 
The  pain  in  inflammation  of  serous  membranes  is  sharp, 
piercing,  stabbing.  The  pain  in  irritation  of  mucous 
membranes  resembles  the  sensation  of  smarting,  burning 
or  soreness.  Muscular  pain  consists  of  an  indescribable 
feeling  of  restlessness  and  fatigue.  Pain  in  the  joints  is 
of  a  deep-seated,  boring,  gnawing  nature. 

2.  Hyperesthesia  (hyperalgesia).  Morbid  increase  of 
the  cutaneous  sensibility  is  recognized  by  the  circum- 
stance that  in  this  condition  of  the  nervous  system    ordi- 

(28) 


GENER  A  L   S  YMP  TO  MA  TO  L  OGY.  29 

nary  exciting  causes  give  rise  to  unusually  painful  feelings 
and  heighten  the  reflex  excitability.  Hyperaesthesia  may 
be  limited  to  circumscribed  areas  of  the  skin.  General 
hyperassthesia  is  probably  due  to  an  irritable  condition 
of  the  spinal  cord.  It  is  a  prominent  symptom  in  teta- 
nus, hydrophobia,  spinal  meningitis,  strychnia  poisoning 
and  hysteria. 

3.  ^?^^s^/^es^a  (analgesia).  All  cases  of  anaesthesia  must 
of  course  depend  on  interruption,  either  central  or  peri- 
pheral, of  sensory  conduction.  Loss  of  the  cutaneous 
sensibility  does  not  constitute  the  only  form  of  anaesthesia. 
The  different  qualities  of  common  sensation  may  be 
wholly  or  separately  abolished.  Tactile  sensibility  is 
simply  tested  by  touching  the  skin  with  a  blunt  instru- 
ment. The  sensation  of  pain  is  conveniently  determined 
by  a  prick  of  the  skin  with  a  needle.  The  experiment 
to  ascertain  whether  a  patient  is  able  to  localize  an 
impression,  or  to  tell  whether  the  contact  has  been  made 
in  one  or  several  placed  at  the  same  time,  may  be  made 
with  the  points  of  a  compass  while  the  patient  has  his 
eyes  closed.  The  appreciation  of  differences  in  tem- 
perature is  tested  by  the  application  of  warm  and  cold 
substances  to  the  skin.  Polysesthesia  is  a  rare  form  of 
partial  anaesthesia.  The  patient  feels  two,  three  or  five 
impressions,  though  only  one  impact  is  made. 

4.  Allochirea  denotes  a  perversion  of  sensibility,  the 
patient  being  uncertain  which  side  of  the  body  is  touched, 
although  the  cutaneous  sensibility  is  normal. 

5.  Analgia  means  that  morbid  condition  of  common 
sensibility  in  which  no  pain  can  be  elicited.  It  is 
observed  in  the   hypnotic  state   and  hysteria.     A  tardy 


30  MA  N  UA  L   OF  NER  VO  US   D  I  SEA  S  ES. 

tninsinission  of  sensory  impression  may  be  the  only  sign 
of  partial  anaesthesia. 

6.  Impairment  of  the  ^'muscrdar  sense^^  is  ascertained 
to  exist  when  the  patient  is  unable  to  appreciate  palpable 
differences  of  weight.  To  exclude  the  tactile  sensibility 
during  the  test  the  weights  should  he  suspended  from 
the  limb.  An  easy  way  of  determining  the  condition  of 
the  muscular  sense  of  the  upper  extremities  is  to  request 
the  patient  to  touch  the  tip  of  his  nose  with  a  finger  ;  if 
defective  the  finger  will  miss  its  mark.  Muscular  con- 
tractility is  best  determined  by  faradization. 

7.  Paresthesia.  Certain  morbid  sensations  which 
patients  compare  to  a  feeling  of  tingling,  creeping,  numb- 
ness or  formication  are  usually  called  paraesthetic.  The 
sensation  as  if  the  limb  were  "asleep,"  or  stuck  with 
^'pins  and  needles,"  flushes  of  heat  in  the  face,  or  a  feel- 
ing of  chilliness  in  some  part  of  the  body  relate  to  the 
same  class  of  sensory  disorders. 

8.  Faralgia.  By  this  term  is  understood  an  anoma- 
lous sensation  that  partakes  more  of  the  feeling  of  con- 
striction than  pain.  A  distressing  sensation  of  this 
character,  which  patients  locate  in  the  region  of  the 
heart,  is  often  called  (precordial  anxiety).  This  symptom 
is  frequentl}'  complained  of  by  nervous  and  hysterical 
individuals.  Tobacco  smokers  are  also  troubled  with  it. 
It  occurs  with  greatest  intensity  in  angina  pectoris. 

VASO-MOTOR    DISTURBANCES. 

Irregularities  of  the  vaso-motor  system  of  nerves  are 
often  associated  with  disease  of  nerve  centers.  Among 
the  two  varieties  of  vaso-motor  nerves — the  vaso-con- 
strictors   and  the  vaso-dilators — the  former  is  of  greater 


GENERAL   SYMPTOMATOLOGY.  31 

pathological  importance.  Experiments  have  determined 
the  existence  of  vaso-motor  centers  in  the  medulla  oblon- 
gata and  the  spinal  cord.  The  vaso-motor  fibres  pass 
into  the  lateral  columns  of  the  spinal  cord,  emerge  from 
there  with  the  anterior  nerve  roots,  and  collect  in  the 
trunk  of  the  sympathetic  nerve  and  plexus. 

Irritation  of  the  vaso-motor  nerves  causes  constric- 
tion of  the  blood  vessels.  Paralysis  of  these  nerves  causes 
dilatation  of  the  vessels. 

The  external  effects  of  vaso-motor  disturbance  are 
chiefly  seen  in  the  skin.  Spasmodic  constriction  of  the 
blood  vessels  produces  pallor  or  cyanosis  of  the  skin.  It 
sometime  causes  a  sensation  of  creeping  and  coldnes  of 
the  hands,  with  which  nervous  and  hysterical  persons  are 
often  troubled.  The  more  severe  effects  of  vaso-motor 
spasm  are  seen  in  malignant  decubitus — Reynaud's  dis- 
ease, circumscribed  gangrene  of  the  extremities  and  the 
eruption  of  dark  bullae  in  different  parts  of  the  skin. 

Paralysis  of  vaso-motor  nerves  gives  rise  to  redness  of 
the  skin  and  the  sensation  of  heat  in  the  affected  part. 
This  condition  is  often  observed  in  hysteria  and  neu- 
rasthenia, and  also  occurs  as  an  independent  affection. 
Weir  Mitchell  has  described  an  analogous  condition  as 
erythromelalgia.  The  redness  and  subjective  feeling  of  heat 
in  this  condition  may  be  persistent  or  occur  at  irregular 
periods.  It  is  attended  by  palpitation  of  the  heart,  strong 
pulsation  of  the  arteries,  anxiety,  ringing  in  the  ears  and 
sweating.  A  milder  affection  of  this  kind  consists  of  a  red 
or  mottled  appearance  of  the  palms  of  the  hands  and  soles 
of  the  feet,  a  distressing  sensation  of  heat  in  these  parts, 
slight  swelling  and  profuse  perspiration. 


3e  M  A  y  UAL   OF  XER  V  OUS   Dl  S  EA  S  ES . 

Trophic  disturbances.  Certain  nntritive  changes  are  now 
supposed  to  be  caused  by  an  independent  set  of  trophic 
nerves.  Examples  of  such  trophic  disorders  are  the 
"glossy  skin,"  the  falling  out  of  the  hair,  stunted  nails 
and  perforating  ulcer  of  the  foot. 

Motor   Disturbances 
The  subjects  under  this  head  include  the  two  impor- 
tant groups  of  convulsive  and  paralytic  affections. 

CONVULSION,      SPASM.       (hYPERKINESIS). 

Convulsion  denotes  an  involuntary  muscular  contrac- 
tion. The  synonymous  term  spasm  is  often  used  to 
express  convulsive  movements  of  a  single  muscle  or  a 
group  of  muscles.  We  speak  of  general  convulsions 
when  the  head,  the  trunk  and  the  extremities  are  simul- 
taneously affected,  as  in  epilepsy.  A  difference  in  the 
character  of  convulsive  movements  underlies  the  distinc- 
tion of  clonic  and  tonic  spasm.  In  clonic  spasm  there  is 
alternate  contraction  and  relaxation  of  a  muscle.  Tonic 
spasm  is  distinguished  by  the  rapid  recurrence  of  the 
contractions,  so  that  the  affected  muscle  appears  to  be  in 
a  fixed  condition.  The  muscle  in  spasm  is  always 
shortened.  Cramp  means  a  painful  contraction.  All 
forms  of  convulsive  movements  are  caused  by  motor  irri- 
tation in  some  part  of  the  nervous  system. 

Contracture  signifies  the  persistent  contraction  of  a 
muscle,  which  fixes  the  limb  either  in  a  flexed  or  an 
extended  position. 

Tremor  consists  of  very  slight  contractions  of  numerous 
bundles  of  muscular  fibres.  The  movements  in  tremor 
are  of  a  very  limited  sweep. 

Fibrillary  contractions  consist  of  a  waving  motion  of 
small  fasciculi  of  muscular  fibres. 


GENERAL  SYMPTOMATOLOGY.  33 

Paralysis  (Akinesis). 

Any  lesion  or  morbid  influence  which  interrupts  the 
conduction  of  motor  impulses  causes  paralysis.  Immo- 
bility of  muscles  from  any  other  cause  is  not  paralysis. 
The  term  paresis  is  used  to  signify  incomplete  paralysis. 

The  classification  of  paralysis,  viewed  anatomically, 
includes  1,  cerebral;  2,  spinal  and  3  peripheral  paralysis. 
The  division  of  the  different  forms  of  paralysis  in  accord- 
ance with  their  area  of  distribution  and  combination 
with  special  morbid  conditions,  is  of  great  clinical  impor- 
tance, and  will  be  briefly  considered  in  this  place. 

1.  Hemiplegia.  This  form  of  paralysis  is  typical  of 
cerebral  disease.  It  occurs  when  any  part  of  the  motor 
tract  above  the  spinal  cord  is  interrupted.  The  paralysis 
affects  the  lateral  half  of  the  body,  namely,  the  face,  and 
the  upper  and  lower  extremity  of  the  side  opposite  to  that 
of  the  lesion  in  the  cerebrum.  This  distribution  of  the 
paralysis  necessarily  results  from  the  crossing  of  the 
motor  tract  in  the  anterior  pyramids. 

2.  Alternate  or  crossed,  paralysis  is  a  form  of  hemiplegia 
in  which  the  arm  and  leg  of  the  side  of  the  body  opposite 
to  that  of  the  lesion  in  the  brain  is  paralyzed,  while  the 
face  or  an  ocular  muscle  of  the  same  side  as  the  lesion  is 
also  involved. 

3.  Monoplegia.  This  is  a  form  of  cerebral  paralysis 
which  either  involves  one  side  of  the  face,  or  one  arm,  or 
one  leg;  or  simultaneously,  the  face  and  tongue,  or  one  side 
of  the  face  and  one  arm.  Such  a  partial  hemiplegia 
occurs  when  a  cerebral  lesion  affects  a  part  of  the  motor 
tract  in  the  brain,  where  its  fibres  are  yet  too  divergent  to 
become  collectively  involved. 

3 


SJf  MANUAL  OF  NERVOUS  DISEASES. 

4.  Paraplegia  is  tj^pical  of  tranverse  disease  of  the 
spinal  cord.  The  paralysis  affects  symmetrical  parts  of 
the  body;  most  frequently  the  two  inferior  extremities. 

5.  Atrophic  paralysis.  The  loss  of  motor  power  in  this 
form  of  paralysis  is  associated  with  atrophy  of  the 
affected  muscles.  When  the  lesion  is  situated  above  the 
spinal  cord  there  is  hemiplegia,  but  rarely  atrophy. 
Atrophic  paralysis  in  central  lesion  of  the  nervous  sys- 
tem occurs  in  disease  of  the  ganglion  cells  of  the  anterior 
cornua  of  the  spinal  cord. 

It  has  bf^en  inferred  from  development  of  atrophic  par- 
alysis in  disease  of  the  anterior  cornua,  that  its  ganglion 
cells  exert  an  influence  on  the  nutrition  of  the  corre- 
sponding muscles  with  which  they  are  connected. 

6.  Spastic  paralysis.  This  form  of  paralysis  is  distin- 
guished by  a  rigid  condition  of  the  affected  muscles. 
The  muscles  are  not  atrophied,  and  offer  resistance  to 
passive  motion.  There  is  usually  exaggeration  of  the 
tendon  reflexes.  The  cause  of  the  rigidity  of  the  muscles 
is  either  a  direct  central  irritation  or  reflex  action. 

7.  Functional  paralysis.  By  this  term  is  understood 
a  group  of  paralyses,  whose  pathology  is  obscure.  It 
includes,  reflex,  hysterical  and  alcoholic  paralysis,  and 
also  those  paralytic  affections  that  occur  as  sequella?  to 
infectious  fevers. 

Besides  the  essential  points  of  distinction  between  the 
different  forms  of  paralyses,  there  are  certain  accessory 
symptoms  which  assist  differential  diagnosis.  These 
refer  to  sensory  and  vaso-motor  disturbances,  and  altera- 
tion of  reflex  and  electric  reaction  which  will  be  described 
in  their  proper  places. 


GENERAL   SYMPTOMATOLOGY.  35 

The  following  explanation  has  been  proffered  to 
account  for  the  exemption  of  certain  groups  of  muscles, 
which  for  anatomical  reasons  would  be  expected  to  become 
also  involved  in  hemiplegia.  The  muscles  of  the  neck, 
the  tongue,  the  eyes  and  the  trunk  are  rarely  found  par- 
alyzed. Those  of  the  jaw^s,  the  pharynx  and  larynx 
always  escape.  This  exemption  or  relative  immunity  is 
due  to  the  circumstance  that  all  these  muscles  act  in 
pairs,  from  which  it  may  be  inferred  that  they  are  inner- 
vated by  both  sides  of  the  brain. 

The  recognition  of  liemijplegia  when  the  patient  is 
unconscious  is  not  always  an  easy  matter.  The  following 
hints  will  assist  the  diagnosis.  On  observing  the  appear- 
ance of  the  face,  it  will  be  noticed  that  the  cheek  "hangs," 
that  it  bulges  during  expiration  and  flaps  during  inspira- 
tion. The  mouth  is  drawn  to  one  side  and  often  saliva 
escapes  from  the  half-opened  lip«.  On  raising  a  paralyzed 
arm  and  then  suddenly  releasing  it  the  limb  falls  down 
like  a  dead  weight.  Sometimes  the  head  and  eyes  are 
turned  to  one  side.  Hemiparesis  is  recognized  with 
greater  difficulty,  even  when  the  consciousness  of  the 
patient  is  clear.  Much  information  may  be  gained  by 
noting  the  position  of  the  limbs  and  the  range  of  their 
voluntary  movements.  The  grasp  of  one  of  the  hands 
is  feeble  in  comparison  with  that  of  the  othe^-  One  cor- 
ner of  the  mouth  is  slightly  drawn  when  the  patient 
laughs  or  cries.  In  the  act  of  walking  his  body  leans 
towards  one  side.  In  place  of  finding  the  paralyzed  limb 
in  a  flaccid  condition  and  passively  movable  in  every 
possible  direction,  which  is  usually  the  case,  it  sometimes 
happens  that  the  arm  is  stiff  and  tightly  pressed  against 
the  chest,  and  the  hands  and  fingers  are  forcibly  flexed. 


^6'  31 A  XUAL   OF  XE RVO  US  DISEASES. 

Occasionally  the  leg  maintains  an  extended  position. 
This  "early  rigidity"  is  characteristic  of  hemiplegia,  but 
it  soon  disappears. 

Hemianscsthesia.  This  is  a  far  less  common  symptom 
in  brain  lesions  than  hemiplegia.  The  special  senses  in 
severe  cases  may  be  more  or  less  simultaneously  affected. 
In  complete  loss  of  the  cutaneous  sensibility,  there  is 
often  obtuseness  of  the  contiguous  mucous  membranes. 
The  lesion  in  central  hemiansesthesia  is  located  either  in 
the  posterior  or  inferior  third  of  the  internal  capsule,  or 
in  the  vicinity  of  the  optic  thalamus  or  lenticular  nucleus. 

Cephalic  Symptoms. 
This  group  of  symptons  includes  headache,  vertigo, 
delirium,  insomnia,  somnolence,  stupor  and  coma.  Occa- 
sionally the  following  adventitious  symptoms  are  quite 
prominent  in  brain  disease:  gastric  derangement,  nausea 
and  vomiting,  disorder  of  the  special  senses  and  epilepti- 
form convulsions. 

1.  Headache  is  a  symptom  attending  a  great  variety 
of  morbid  conditions,  but  is  usually  of  little  diagnostic 
importance.  Very  violent  and  persistent  pain  in  the 
head  is,  however,  an  early  and  constant  symptom  of 
meningitis,  cerebral  tumor,  cerebral  syphilis  and  cerebral 
abscess.  Infants  manifest  severe  headache  by  a  peculiar 
abrupt  cry,  and  boring  of  the  head  into  the  pillow. 

2.  Vertigo,  like  headache,  is  due  to  different  causes.  In 
numerous  cases  it  merely  amounts  to  a  slight  sensation  of 
dizziness.  Sometimes  it  is  an  obstinate  and  troublesome 
symptom  a^.d  calls  for  special  treatment  (essential  ver- 
tigo.) The  patient  in  severe  cases  has  the  sensation  of 
"  swimming"  in  the  head,  or  as  if  external  objects  con- 


G  EXER  A  L   S  Y M P  T 0  MATOLO  G  Y .  37 

stantly  moved  around  him.  Anaemic  persons  and  inva- 
lids after  fever  are  liable  to  vertiginous  attacks  on  suddenly 
assuming  the  erect  position.  Vertigo  attended  by  a 
momentary  confusion  of  the  mind  constitutes  one  of  the 
minor  forms  of  epilepsy.  Gastric  disorders,  aflfections  of 
the  eye  and  the  ear,  alcoholism  and  masturbation  fre- 
quently give  rise  to  vertigo.  Associated  with  deafness, 
nausea  and  vomiting,  it  constitutes  a  very  prominent 
symptom  in  Meniere's  disease.  A  reeling  gait  resembling 
the  effects  of  severe  vertigo  is  a  characteristic  sign  of 
cerebellar  disease.  In  regard  to  the  nature  of  vertigo,  it 
appears  to  indicate  an  abnormal  condition  of  the  con- 
sciousness in  relation  to  the  position  of  the  body.  There 
is  a  disturbance  of  the  sense  of  equilibrium. 

3.  Delirium.  The  diagnostic  value  of  delirium  is  not  of 
a  high  order.  It  is  a  symptom  arising  under  influences  of 
various  and  opposite  pathological  conditions.  Delirium 
may  assume  all  conceivable  grades  of  mental  excite- 
ment, from  transient  periods  of  wandering  to  maniacal 
frenzy.  It  may  present  all  the  features  of  insanity;  but 
the  incoherence  of  language  and  the  morbid  mental  con- 
dition pass  off  with  the  affection  that  gave  rise  to  the 
disturbance.  In  certain  nervous  diseases,  however,  much 
significance  attaches  to  the  peculiarity  of  the  psychical 
derangement.  The  hallucinations  in  delirium  tremens 
are  repulsive  and  frightful  to  the  patient.  The  demented 
paralytic  revels  in  delusions  of  grandeur  and  exaltation. 

4.  Insomnid.  Sleep  is  often  much  disturbed  in  func- 
tional nervous  disorders.  An  excited  or  ill-nourished 
brain  is  incompatible  with  the  conditions  of  rest  and 
quiet.  Wakefulness  is  frequent!}^  an  initial  symptom  of 
insanity,  and  is  a  very  common  feature  of  chronic  alco- 


93320 


38  MA  N  UAL  OF  NER  V OUS  D IS EA  SES . 

holism.  Insomnia,  accompanied  by  severe  headache, 
is  often  a  marked  symptom  of  cerebral  syphilis.  Short 
snatches  of  sleep  disturbed  by  unpleasant  dreams  more 
commonly  result  from  orastric  or  intestinal  irritation  than 
from  cerebral  trouble. 

5.  Somnolence.  A  disposition  to  sleep  at  unusual  hours 
is  observed  in  cerebral  ansemia  and  chlorosis.  Great 
drowsiness  may  be  a  premonitory  symptom  of  ursemic 
convulsions.  Brain  disease  in  children  is  often  ushered  in 
by  prolonged  and  deep  sleep.  The  so-called  "  inward 
fits"  in  infants  come  on  during  sleep.  The  child  grinds 
its  teeth,  turns  the  eyes  upwards,  presses  the  fingers 
tightly  on  the  palm  of  the  hand  and  flexes  the  toes 
downwards  (carpo-pedal  spasm).  These  symptoms  usu- 
ally pass  off  without  any  serious  consequences,  but  some- 
times the  little  patient  awakes  with  a  start  and  cries 
incessantly,  or  has  an  attack  of  convulsions. 

6.  Stupor,  Coma.  Consciousness  may  be  disturbed  in 
different  degrees.  A  bewildered  or  dazed  condition  of 
the  mind  is  often  occasioned  by  powerful  mental  excite- 
ment. Coma  is  usually  ushered  in  by  stupor,  from  wliich 
the  patient  can  still  be  roused.  In  profound  coma  there 
is  a  total  abolition  of  the  perceptive  powers.  Loss  of  con- 
sciousness and  utter  insensibilit}^  constitute  the  essential 
symptoms  of  cerebral  apoplexy.  The  usual  mode  of 
death  in  cerebral  disease  is  by  coma. 

7.  Gastric  symptoms  attending  brain  affections  are 
probably  of  a  reflex  character,  affecting  the  pneumo- 
gastric  nerve.  "Cerebral  vomiting"  is  recognized  by  the 
absence  of  a  palpable  cause  of  gastric  irritation.  This 
symptom  is  so  frequently  present  in  children  threatened 
with  serious  brain  trouble  that  due  weight  must  be  given 


G EJS^ERA  L   S  Y MP  TO 21 A  TOLO G  Y.  S9 

to  its  appearance.  Brain  lesions  occasionally  give  rise 
to  gastric  disturbances  of  such  great  severity  and  persist- 
ence so  as  to  mask  the  real  cause  for  a  considerable 
length  of  time.  Abernethy  relates  the  case  of  a  young 
woman  whom  he  treated  for  what  he  thought  to  be  some 
serious  stomach  affection.  At  the  autopsy  he  found  a 
large  abscess  of  the  brain:  the  stomach  was  perfectly 
healthy. 

8.  Epileptiform  convulsions.  All  grave  diseases  of  the 
brain  tend  to  develop  spasmodic  seizures.  Cortical 
lesions  are  especially  prone  to  give  rise  to  epileptiform 
convulsions  (Jacksonian  Epilepsy.)  Unilateral  convul- 
sive movements  or  when  one  side  is  more  affected  than 
the  other  are  usually  dependent  upon  gross  lesion 
of  the  cerebrum.  Epileptiform  attacks  frequently  occur 
in  tumor,  abscess  and  syphilis  of  the  brain,  and  less 
frequently  in  meningeal  and  cerebral  hemorrhage  and 
embolism. 

9.  Infantile  convulsions.  Children  of  a  tender  age  are 
exceedingly  prone  to  spasmodic  attacks,  though  in  the 
greater  number  of  cases  they  take  a  favorable  termina- 
tion. The  unstable  condition  of  the  nervous  system  in 
the  very  young  offers  but  slight  resistance  to  trifling 
exciting  causes,  and  in  consequence  reacts  in  an  excessive 
manner.  Many  children  are  readily  thrown  into  spasms 
by  difficult  dentition,  and  gastric  or  intestinal  derange- 
ment from  the  presence  of  indigestible  food  or  worms.  It 
is  a  matter  of  daily  experience  that  acute  diseases 
occurring  in  early  childhood  are  often  ushered  in  by  gen- 
eral convulsions.  Sometimes  it  is  difficult  to  foretell 
whether  the  sudden  onset  of  the  spasms  indicates  the 
establishment   of  some   formidable  disease   (meningitis, 


40  J/ .4  .V  U A  L   0  F  XER  V  O  US   DIS  EA  S  ES . 

pneumonia,  scarlatina,  etc.),  or  is  merely  the  temporary 
effect  of  a  source  of  reflex  irritation,  or  perhaps  the  fore- 
runner of  epiiej^sy. 

10.  Nervousness.  This  vague  expression  much  in  vogue 
in  popular  pathology  has  not  yet  been  admitted  into 
medical  nomenclature.  It  is  nevertheless  true  that 
patients  often  complain  of  numerous  and  anamolous 
symptoms  which  cannot  be  fairly  labeled  with  the  names 
of  well-known  nervous  affections.  A  fruitful  source  of 
such  undefinable  ailments  is  undoubtedly  dependent  on 
an  enfeebled  condition  of  the  general  nervous  system, 
however  brought  on.  Such  patients  often  exhibit  a  con- 
stitutional tendency  to  become  readily  excited,  depressed 
or  emotional.  Among  the  special  causes  may  be  men- 
tioned fi*equent  loss  of  small  quantities  of  blood,  debili- 
tating discharges,  excesses  of  every  kind,  prolonged 
mental  depression  and  the  incipient  stage  of  many  chronic 
diseases.  Conditions  of  this  nature  often  underlie  ner- 
vous dyspepsia,  insomnia,  the  hysterical  or  hypochondric 
disposition  and  neurasthenia. 

11.  Ocular  symjDtoms.  The  clinical  significance  of 
pupillary  changes  can  only  be  adequately  appreciated  if 
the  reflex  mechanism  regulating  the  movements  of  the 
iris  be  properly  understood.  The  size  of  the  pupil  in 
health  is  determined  by  the  quantity  of  light  which  enters 
the  eye,  and  by  the  act  of  accommodation.  The  pupils 
contract  when  exposed  to  light,  and  dilate  in  the  dark. 
They  contract  when  looking  at  near  objects,  they  dilate 
when  looking  at  distant  objects.  As  long  as  there  exists 
but  the  feeblest  sensibility  to  light,  the  pupillary  reaction 
occurs,  whether  the  light  falls  upon  one  or  both  eyes. 
Contraction  of  the  pupil  is  in  direct  proportion  to  the 


GENERAL  SYMPTOMATOLOGY.  4I 

quantity  of  light  impinging  on  the  retina.  The  stimulus 
of  light  acting  upon  the  retina  is  transmitted  by  the  optic 
path  to  its  cortical  center  and  excites  on  reflex  action 
the  branches  of  the  motor  oculi  that  connect  >vith  the 
iris.  Derangement  of  any  of  the  integral  parts  of  this 
reflex  mechanism  is  manifest  by  abnormal  reaction  of 
the  pupils. 

12.  Optic  neuritis  is  a  symptom  of  great  frequency  in 
cerebral  disease.  The  change  in  the  optic  nerve  when 
the  fundus  of  the  eye  is  examined  by  the  ophthalmo- 
scope, is  characterized  at  the  beginning  by  congestion 
and  oedema,  and  if  the  inflammation  does  not  subside,  very 
marked  changes  take  place,  which  are  implied  by  the 
term  '"choked  disk."  The  arteries  are  reduced  in  size,  the 
veins  are  enlarged  and  tortuous,  and  finally  atrophy  of 
the  disk  ensues.  Vision  is  often  unimpaired,  although 
the  alterations  discovered  by  the  ophthalmoscope  show 
the  existence  of  optic  neuritis.  The  optic  neuritis 
observed  in  cerebral  disease  is  bilateral  and  must  be  dis- 
tinguished from  that  form  which  results  from  local 
causes.  Primary  optic  atrophy  tending  to  amaurosis 
occurs  in  locomotor  ataxia.  The  ophthalmoscopic  appear- 
ance of  optic  neuritis  bears  great  resemblance  to  that  of 
albumenuric  retinitis. 

13.  Paralysis  of  ocular  muscles.  Isolated  and  com- 
bined paralysis  of  ocular  muscles  occur  in  diseases  affect- 
ing the  pons,  the  crus  and  base  of  the  brain.  Paralysis  of 
the  external  ocular  muscles  is  manifested  by  the  occur- 
rence of  strabismus,  diplopia  or  ptosis.  In  paralysis  of 
the  ciliary  muscles,  there  may  be  loss  of  accommodation, 
or  the  reflex  contraction  of  the  iris  in  looking  at  near 


Jf2  MA  N  UA  L   OF  NER  VOUS  DIS  EA  S  ES . 

objects  may  be  intact,  whilst  the  pupils  do  not  contract 
on  exposure  to  light.  This  symptom  is  known  as  the 
''Argyle-Robertson  pupil."  It  is  sometimes  observed  in 
locomotor  ataxia  and  cerebral  syphilis.  Inequality  of 
the  pupils  is  often  an  early  symptom  of  general  paresis 
of  the  insane.  Pupillary  changes  are  observed  in  disease 
of  the  spinal  cord  when  the  oculo-spinal  center  is  aftected. 
Reflex  irritation  of  the  cervical  sympathetic  is  probably 
the  cause  of  dilatation  of  the  pupils  in  migraine, 
nephritic  colic  and  in  children  troubled  with  worms.  It 
should  be  remembered  that  pupillary  changes  and 
paralysis  of  external  ocular  muscles  frequently  depend 
on  local  causes. 

Hemianopsia,  which  means  blindness  of  one  lateral 
half  of  the  retina,  is  a  sympton  of  much  diagnostic 
importance.  The  most  common  form  of  hemianopsia  is 
blindness  of  the  nasal  half  of  one  eye,  and  of  the  temporal 
half  of  the  other  eye.  The  usual  test,  if  a  perimeter  is 
'not  used,  is  to  close  one  of  the  patient's  eyes  with  the 
finger  and  to  request  him  to  fix  the  open  eye  upon  one  spot 
or  a  near  object.  Standing  in  front  of  the  patient,  the 
examiner  passes  the  unemployed  hand  up  and  down  and 
to  the  right  and  left  of  the  object  at  which  the  patient  is 
gazing,  and  asks  him  whether  he  sees  the  hand  dis- 
tinctly and  simultaneously  with  the  object  he  looks  at. 
If  he  does  not,  then  the  retina  is  blind  on  the  side 
opposite  to  that  on  which  the  sight  of  the  hand  is  lost. 
Hemianopsia  has  been  observed  in  lesion  of  the  cuneiform 
convolution  of  the  occipital  lobe,  and  also  in  lesion  of  the 
cerebrum,  which  implicates  the  optic  tract  or  chiasm. 
Hemianjesthesia  is  sometimes  attended  by  Hemianopsia. 


GENERAL  SYMPTOMATOLOGY.  4^ 

14.  Auditory  symptoms.  Disorder  of  the  auditory 
nerve  is  not  often  witnessed  in  cerebral  disease.  General 
ansemia  is  sometimes  attended  by  a  buzzing  or  humming 
noise,  or  sounds  resembling  the  tinkling  of  bells.  There  is 
reason  to  infer  that  the  temporal  lobe  is  the  central  destina- 
tion of  the  auditory  nerve.  Deafness  of  one  ear  has  been 
observed  when  the  auditory  path  between  the  medulla 
and  the  superior  temporal  convolution  of  one  side  was 
involved  in  a  lesion. 

15.  Disturbance  of  the  function  of  the  olfactory  nerve  is 
rarely  noticed  in  cerebral  disease.  Hemianesthesia  is 
sometimes  accompanied  by  loss  of  smell  on  the  affected 
side.  Hysterical  patients  occasionally  experience  per- 
version or  obliteration  of  the  sense  of  smell. 

16.  It  is  difficult  to  recognize  disorder  of  the  sense  of 
taste.  The  gustatory  sense  is  sometimes  abnormally 
acute  or  perverted  in  hysteria.  Nothing  definite  is 
known  concerning  the  central  destination  of  the  gusta- 
tory nerve. 

17.  Paralysis  of  the  sensory  portion  of  the  fifth  nerve, 
which  is  of  rare  occurrence,  causes  anaesthesia  from  the  ver- 
tex to  the  lower  jaw,  and  loss  of  sensibility  of  the  mucous 
membrane  of  the  nose,  tongue  and  mouth  on  the  same  side. 
The  most  serious  effect  resulting  from  paralysis  of  the 
nerve  is  atrophy  and  ulceration  of  the  cornea.  Paralysis 
of  the  motor  portion  of  the  fifth  nerve  causes  weakness  of 
the  masticatory  muscles  of  one  side.  Eventually  the 
temporal  and  zygomatic  fossae  become  flattened  from 
wasting  of  the  fronto-temporal  and  masseter  muscles. 

18.  A  lesion  in  the  path  of  the  facial  nerve  above  its 
nucleus,  between  it  and  its  cortical  destination,  causes 
paralysis  of  the  face  on  the  opposite  side.     Paralysis  of 


U  MANUAL   OF  NERVOUS  DISEASES. 

the  face  on  the  same  side  as  the  lesion  happens  when  the 
facial  is  implicated  in  the  vicinity  of  the  pons  varolii.  It 
is  usually  observed  that  in  hemiplegia,  only  the  mus- 
cles of  the  lower  half  of  the  face  are  affected.  This 
shows  that  the  lesion  has  involved  the  central  path  of 
the  facial. 

19.  Circulatory  disturbances.  Alterations  of  the  pulse 
are  not  commonly  observed  in  chronic  affections  of  the 
brain.  The  pulse  in  acute  meningitis  is  variable.  It 
may  be  rapid,  wiry  and  jerky,  or  abnormally  slow  and 
feeble,  irregular  or  intermittent.  The  full,  bounding 
pulse  in  cases  of  cerebral  hemorrhage  is  often  due  to  ven- 
tricular hypertrophy. 

20.  The  tache  cerebral  is  a  test  to  determine  the  condi- 
tion of  the  cutaneous  circulation  which  is  frequently 
depressed  in  cerebral  disease.  On  passing  the  finger 
somewhat  firmly  across  the  upper  part  of  the  inguinal 
region  or  the  inner  aspect  of  the  thigh,  a  red  streak 
appears  after  the  removal  of  the  finger,  which  but  slowly 
fades  w^hen  the  circulation  is  feeble. 

21.  By  the  term  ''  cerebral  breathing"  is  understood 
a  morbid  alteration  of  the  act  of  respiration,  which  is  of 
bad  omen  in  brain  trouble.  The  breathing  is  noisy,  nasal 
and  interrupted.  An  aggravated  kind  of  cerebral  breath- 
ing is  known  as  the  "Cheyne-Stokes  respiration."  It 
consists  of  a  series  of  respiratory  movements  that  attain 
to  a  great  rapidity  and  then  gradually  become  exceed- 
ing slow. 

Spinal  Symptoms. 
Sensory  disturbances.     Pain  in  the  region  of  the  verte- 
bral column  is  a  rare  symptom  in  chronic  affections  of 
the  spinal  cord;  but  violent  rhachialgic  pain  coming  on 


G  ENER  A  L   S  YMP  TO  MA  TO  LOGY.  45 

spontaneously  or  aggravated  by  movement  of  the  body, 
occurs  in  spinal  meningitis  and  intraspinal  tumor.  Gen- 
eral hy2)ercrstliesia  is  a  marked  symptom  of  irritation  of 
the  spinal  cord.  It  is  observed  in  spinal  meningitis, 
tetanus,  hydrophobia  and  hysteria.  The  reflex  excita- 
bility is  usually  heightened  in  this  condition.  Tender- 
ness of  the  vertehrse  usually  limited  to  the  cervical 
and  upper  dorsal  regions  independent  of  disease  of  the 
bones  or  spinal  cord  is  probably  of  a  hypersesthetic  char- 
acter (points  apophysaire).  This  is  the  essential  symp- 
toms of  "spinal  irritation,"  but  it  is  often  associated 
with  dorso-intercostal  neuralgia.  A  dull  constricting 
sensation  encircling  the  waist  frequently  attending  dis- 
ease of  the  spinal  cord  is  called  the  "girdle" or  "cincture" 
sensation. 

Motor  Symptoms. 
Paraplegia  is  the  typical  form  of  paralysis  in  inflamma- 
tion of  the  spinal  cord.  In  the  vast  majority  of  cases 
the  inferior  extremities  are  affected.  The  paralysis  varies 
from  complete  loss  of  the  muscular  movements  to  incom- 
plete paralysis  or  paraparesis.  In  mild  cases  there  is  a 
shuffling  gait,  or  the  patient  is  able  to  walk  only  with  the 
aid  of  crutches.  Sometimes  the  paraplegia  merely  amounts 
to  muscular  weakness  of  the  legs.  The  distribution  of  the 
paralysis  varies  with  the  seat  of  the  disease  in  the  cord. 
The  lesion  may  affect  the  lumbar,  the  dorsal  or  the  cerv- 
ical region,  though  in  the  greater  number  of  cases  the  lesion 
is  in  the  lumbar  cord.  In  severe  lesion  of  the  cervical 
cord  all  four  extremities  are  paralyzed.  Sometimes  the 
paralysis  of  one  lower  extremity  is  more  complete  than  in 
the  other,  and  may  simulate  hemiplegia.  In  very 
exceptional  cases  one  lateral  half  of  the  spinal  cord  is 


46  MANUAL   OF  NERVOUS  DISEASES. 

involved.  The  motor  paralysis  in  conformity  with  the 
anatomical  arrangement  of  this  organ  is  on  the  same  side 
as  the  lesion,  and  the  anaethesia  on  the  other  side. 

Impairment  of  the  sphincters  of  the  bladder  and  rectum 
occurs  in  transverse  myelitis.  Weakness  of  the  bladder 
from  this  cause  is  recognized  by  imperfect  evacuation  of 
the  urine.  As  the  disease  advances,  the  urine,  on  being 
retained,  decomposes  and  becomes  ammoniacal,  which 
tends  to  develop  cystitis  and  pyelitis.  Rectal  paralysis 
causes  obstinate  constipation  and  finally  involuntary  dis- 
charges. 

Weakness  of  the  sexncd  fnnction  usually  accompanies 
the  paralysis  of  the  sphincters.  It  is  indicated  by  imper- 
fect erections  tending  to  complete  loss  of  the  sexual  power. 

Tests  of  reflex  action.  Alteration  of  the  reflexes  is  a  com- 
mon symjDtom  in  spinal  disease.  Reflexes  are  of  two 
kinds,  the  superficial  and  the  deep.  The  former  are 
excited  by  irritating  the  cutaneous  surface;  the  latter  by 
exciting  the  tendons  or  fascia  of  muscles.  Tickling  or 
pinching  the  skin  is  the  usual  manner  of  eliciting  the 
cutaneous  reflexes.  A  more  elegant  method  consists  in 
stimulating  the  skin  with  the  faradic  current. 

1.  The  plantar  reflex  is  excited  on  tickling  the  sole  of 
the  foot.  It  causes  a  jerking  movement  of  the  limb, 
through  the  action  of  the  gastrocnimii  muscles. 

2.  The  cremaster  reflex  is  obtained  on  pinching  the  inner 
side  of  the  thigh.     This  causes  retraction  of  the  testicle. 

3.  The  gluteal  reflex  is  induced  on  pinching  the  skin  in 
the  region  of  the  buttock. 

4.  The  epigastric  reflex  is  excited  on  irritating  the  skin 
of  the  chest  between  the  fifth  and  sixth  intercostal  spaces. 
It  causes  dimpling  of  the  epigastrium. 


GENER  A  L  S  YMP  TOM  A  TO  LOG  Y.  47 

The  most  important  of  the  deep  reflexes  are  the  patellar 
tendon  reflex  and  the  ankle  clonus. 

5.  Patellar  reflex  (knee  jerk).  One  of  the  methods  of 
eliciting  this  reflex  consists  in  letting  the  patient  sit  on  a 
chair,  one  leg  being  crossed  over  the  other  so  that  it  does 
not  touch  the  floor.  A  light  tap  with  the  edge  of  the 
hand  on  the  patellar  ligament  immediately  below  the 
knee  cap  causes  the  foot  to  jerk  forward  through  the 
action  of  the  rectus  femoris  muscle.  Another  method  of 
inducing  the  knee  jerk,  only  practiced  on  males,  is  to 
raise  and  support  the  thigh  by  passing  one  hand  beneath 
it,  just  beyond  the  knee  joint,  and  to  grasp  the  knee  of 
the  other  leg.  The  tap  is  then  made  at  the  proper  point 
of  the  free  leg.  Experiments  in  healthy  individuals  show 
considerable  differences  in  regard  to  the  energy  of  the 
patellar  reaction. 

6.  In  exciting  the  ankle  clonus  the  leg  is  slightly  bent 
upon  the  thigh  and  supported  by  placing  the  hand  under 
it  near  the  knee  joint.  The  toes  are  seized  with  the  fin- 
gers and  pulled  forward,  so  as  to  stretch  the  tendon 
Achillis.  On  suddenly  flexing  the  foot,  while  the  fingers 
continue  to  press  against  the  toes,  a  series  of  rythmical 
contractions  of  the  calf  muscles  ensue.  The  ankle  clonus 
is  not  as  readily  excited  as  the  patellar  reflex. 

Inhibition.  There  is  good  reason  to  infer  the  existence 
of  an  anatomical  mechanism,  probably  in  the  spinal  cord, 
which  controls  reflex  action  independent  of  the  will.  We 
know,  that  by  an  effort  of  the  will,  we  often  succeed  in 
suppressing  a  strong  inclination  to  laugh  or  to  cry,  and 
sometimes  we  are  able  to  restrain  a  fit  of  sneezing  or 
coughing.  When  infantile  convulsions  are  checked  by  a 
warm  mustard  bath  we  have  an  analogous   illustration 


J^  MA  X  U  AL  OF  XER  VOUS  D  IS  EA  S  ES . 

of  the  controlling  influence  of  an  artificial  impression. 
Brown-Seqnard  put  a  stop  to  spinal  spasm  by  forcible 
flexion  of  the  big  toe.  In  these  examples  it  may  be  said 
that  the  reflex  action  which  produced  the  spasm  has  been 
inhibited.  Inhibition  may  therefore  be  supposed  to  take 
place  when  a  center,  which  is  the  medium  of  reflex  action 
looses  its  excitability  on  being  acted  upon  by  a  nervous 
influence  which  forms  a  part  of  the  same  reflex  mechan- 
ism. Perhaps  many  an  anomalous  phenomena  in  ner- 
vous and  hysterical  individuals  is  due  to  defective  inhib- 
itory action. 

The  subject  of  incoordination  will  be  more  conveniently 
considered  in  connection  with  locomotor  ataxia. 


CHAPTER  III. 

GENERAL  THERAPEUTICS  OF  NERVOUS 
DISEASES. 

ReM.  Whilst  in  surgical  treatment,  absolute  rest  is  often 
of  itself  curative,  the  beneficial  influence  of  relaxation 
from  nervous  strain  and  exhaustion  is  not  as  frequently 
insisted  upon  as  it  should  be.  The  benefit  derived  from 
the  tonic  and  bracing  effects  of  mountain  air  or  a  sojourn 
at  the  seaside  cannot  be  overrated.  Many  an  overworked 
person,  broken  down  in  health,  who  constantly  complains 
of  languor,  sleeplessness,  dyspepsia  and  a  host  of  other 
nervous  ailments  that  had  baffled  the  ordinary  remedies 
has  returned  from  one  of  these  resorts  completely  restored. 
Probably  the  chief  factor  in  this  happy  change  was  the 
release  from  unremitting  attention  to  business  and  the 
worry  it  entails. 

The  treatment  introduced  by  Weir  S.  Mitchell  in 
aggravated  cases  of  functional  derangement  of  the  ner- 
vous system  in  females  frequently  meets  with  brilliant 
success.  It  chiefly  consists  in  seclusion  of  the  patient 
and  in  securing  rest  and  quietude.  Active  exercise  is 
replaced  by  electricity  and  massage.  The  diet  is  strictly 
controlled  by  the  attending  physician. 

Diet.  Derangement  of  the  digestive  functions  fre_ 
quently  attends  nervous  disorder,  and  in  turn  a  reduced 

4  M9) 


50  M  A  ^  U A  L    0 F  X ER  V O  C S   D  I S E A  S E S  . 

tone  of  the  nervo-muscular  apparatus  develops  an 
enfeebled  digestion.  This  vicious  circle  of  morbid  intlu- 
ences  may  causeembarrassment  of  diagnosis.  Dyspeptic 
symptoms  obstinate  to  treatment  are  often  but  the  mani- 
festations of  nervous  depression.  It  can  hardly  be 
expected  that  anorexia,  nausea  and  epigastric  uneasiness 
brought  on  by  anxiety,  disappointment  and  other  mental 
trouble,  perhaps  bad  habits,  will  yield  to  regulation  of 
diet  and  reputed  anti-dyspeptic  remedies.  A  starving 
dietary  would  surely  augment  the  mischief.  On  the  con- 
trary, sufficient  substantial  nourishment  is  called  for,  and 
the  medical  attendant  will  do  well,  who,  under  these  cir- 
cumstances, succeeds  in  weaning  his  patient  from  the 
domineering  caprice  of  a  squeamish  stomach.  Above  all, 
nervous  patients  should  be  warned  against  yielding  to  the 
seductive  fascination  of  alcoholic  stimulants,  however 
much  they  may  afford  temporary  relief.  What  may  be 
called  ''nervous  dyspepsia"  is  very  often  but  the  obtrusive- 
ness  of  digestive  symptoms  among  manifold  complaints 
that  arise  in  general  deterioration  of  health  from  whatever 
cause. 

Opium.  Among  the  internal  remedies  in  the  treatment 
of  nervous  diseases,  none  are  as  frequently  employed  as 
the  narcotics.  These  substances  relieve  pain,  promote 
sleep,  arrest  spasm,  and  often  exert  a  beneficial  influence 
on  the  course  of  many  diseases.  The  therapeutical  prop- 
erties of  opium,  especially  its  chief  alkaloid,  morphia, 
are  not  equaled  in  eflficacy  by  any  other  of  the  class  of 
sedatives.  Since  the  introduction  of  the  hypodermic 
syringe,  the  desired  promptness  of  action  of  morphia  and 
its  compeers  can  be  obtained. 


GENERAL    THERAPEUTICS.  Bi 

Codeia  is  a  good  substitute  for  morphia,  when  the  latter, 
owing  to  idiosyncrasy,  cannot  be  tolerated.  It  is  not  so 
likely  to  derange  the  stomach  or  to  confine  the  bowels  as 
morphia,  but  is  less  reliable  in  its  action,  and  must  be 
given  in  relatively  larger  doses.  As  a  general  rule  it 
cannot  take  the  place  of  morphia,  but  very  strange  sus- 
ceptibilities are  sometimes  witnessed.  I  remember  the 
ease  of  a  young  man  who  suffered  from  chronic  ulcer  of 
the  stomach.  His  attacks  of  hematemesis  were  frequently 
attended  by  violent  cardialgia.  'Hypodermics  of  morphia 
invariably  brought  on  epileptiform  convulsions,  while 
codeia  gave  prompt  relief. 

Belladonna.  It  must  be  said  in  favor  of  belladonna 
that  it  sometimes  exerts  a  sedative  effect  when  morphia 
fails.  Owing  to  the  antagonism  of  these  powerful  rem- 
edies they  are  often  given  in  combination.  The  tincture 
of  belladonna,  or  the  extract,  is  often  useful  in  neuralgia, 
gaslralgia,  whooping  cough  and  spasmodic  affections. 
This  remedy  still  retains  some  reputation  in  the  treat- 
ment of  epilepsy.  The  parvules  of  atropia  of  different 
strengths  afford  a  reliable  and  convenient  mode  of  pre- 
scribing this  medicine.  Extreme  caution  is  advisable  in 
the  use  of  this  powerful  remedy. 

Hyosciamus.  The  hypnotic  effects  of  this  remedy  sug- 
gest its  use  when  opium  is  indicated,  but  it  is  far  less 
certain.  Hyosciamine  in  doses  of  gr.  1-150  has  been 
found  useful  in  tremor. 

Aconite.  Remarkable  cures  of  inveterate  facial  neural- 
gia are  reported  from  aconitia.  This  dangerous  alkaloid 
is  given  in  doses  of  gr.  1-200. 

Stramonium  leaves  enter  into  the  composition  of  cigar- 
ettes and  pastiles  for  the  relief  of  asthma. 


5^  MA  N UA  L    OF  N  ER  VO  US   D/S EA  SES . 

Calabar  bean.  Its  alkaloid  _p/j2/sosfi^r/ja  has  been  chiefly 
employed  in  the  treatment  of  tetanus. 

Canabis  Inclica  sometimes  acts  well  as  a  hypnotic  and 
in  mild  forms  of  neuralgia. 

Conium.  This  remedy  is  little  used.  Alienists  ascribe 
to  it  the  eflfect  of  subduing  maniacal  excitement. 

Chloral  hydrate  is  one  of  the  best  hypnotics  we  possess, 
though  it  does  not  relieve  pain  like  morphia.  This 
remedy  is  often  of  signal  service  in  acute  alcoholism. 

Chloroform.  This  valuable  anaesthetic  is  often  our  last 
resort  in  severe  and  protracted  forms  of  spasmodic  parox- 
ysms. 

The  bromides  form  a  class  of  remedies  of  great  value. 
They  lower  reflex  excitability  and  exert  a  general  sooth- 
ing eff'ect  on  the  nervous  system.  Bromide  of  potassium 
alone  or  in  combination  with  other  bromides  is  our  sheet 
anchor  in  epilepsy.  Large  doses  of  this  drug  promote 
sleep. 

Alcohol  in  the  form  of  whisky,  brandy  or  wine  is  unsur- 
passed as  a  restorative  in  shock  or  sudden  nervous  pros- 
tration. These  liquors  cannot  be  replaced  by  any  other 
remedies  when  reliable  stimulants  are  indicated. 

Gelseminum  sempervirens.  The  tincture  or  fluid  extract 
of  yellow  jessamine  is  strongly  recommended  in  neuralgia 
of  the  dental  nerve.  This  remedy  is  said  to  quiet  the 
"  hydrocephalic  cry"  in  meningitis. 

Aniipyrin,  Phenacetin,  Sulfonal.  These  newly  intro- 
duced remedies  possess  undoubted  analgesic  qualities. 
Their  excellent  effects  in  nervous  headache  is  especially 
praised.     Sulfonal  does  good  service  in  insomnia. 


GENERAL    THERAPEUTICS.  53 

Paraldehyde  is  well  adapted  to  allay  the  mental  excite- 
ment and  worry  of  hysterical  patients.  It  is  also  a 
hypnotic. 

Phosphorus  is  now  much  prescribed  as  a  nervine  tonic. 
Its  reputation  has  yet  to  be  established. 

Strychnia.  This  powerful  excitant  o'f  the  axial  nerve 
center  was  formerly  the  most  favorite  remedy  in  all  par- 
alytic affections.  Its  use  has  been  in  a  great  measure 
superseded  by  electricity.  Subcutaneous  injections  act 
sometimes  favorably  in  feebleness  of  the  bladder  and 
rectum  and  impairment  of  the  sexual  function. 

Iodide  of  potassium.  Independent  of  the  antisyphilitic 
action  of  this  remedy,  a  considei*able  influence  in  con- 
trolling tissue  changes  of  a  low  inflammatory  character 
may  be  claimed  for  it.  The  good  effects  not  infrequently 
witnessed  from  its  employment  in  cases  where  no  history 
of  syphilis  exists,  justifies  such  a  favorable  opinion. 

Musk,  camphor,  ether,  aromatic  spirit  of  ammonia, 
sweet  spirits  of  nitre  and  valerian  are  frequently  useful 
for  the  relief  of  nervous  depression  and  various  functional 
ailments. 

Among  the  empirical  remedies  most  frequently  used 
with  advantage  in  the  treatment  of  chronic  nervous  dis- 
eases, belong  arsenic,  nitrate  of  silver  and  preparations 
of  zinc  and  ^old. 

Medical  Electricity. 
The  importance  of  electricity  as  an  invaluable  thera- 
peutical   agent   in    the    treatment    of  nervous    diseases 
demands    for   it   a  larger  space  than  has  been  assigned 
to  the  consideration  of  other  classes  of  remedies. 


64  MANUAL   OF  NERVOUS  DISEASES. 

The  electric  currents  in  use  in  medical  practice  include 
the  galvanic  and  faradic  currents.  Static  electricity  is 
as  yet  very  little  employed. 

(ralranum.  (voltaism,  constant  current,  battery  cur- 
rent.) Galvanic  electricity  is  generated  by  the  contact 
of  dissimilar  metals  which  are  submitted  to  chemical 
action.  The  simplest  arrangement  consists  of  the  combi- 
nation of  a  plate  of  zinc  and  copper  or  of  carbon  immersed 
in  a  glass  vessel  containing  dilute  sulphuric  acid.  To 
each  of  the  plates  outside  of  the  fluid,  a  wire  is  attached, 
and  as  soon  as  these  wires  are  joined,  a  current  of  elec- 
tricity is  established  which  continues  to  flow  until  the 
plates  are  oxidized.  Such  an  arrangement  is  called  a 
cell  or  an  element.  The  combination  of  a  number  of 
cells  consisting  of  an  alternate  series  of  dissimilar  metals 
constitute  a  battery.  The  terminal  of  the  wire  connected 
with  the  copper  plate,  the  last  in  the  series,  is  the  positive 
pole  or  the  anode.  That  connected  with  the  zinc  plate 
at  the  other  end  of  the  series  is  the  negative  pole  or  the 
lathode. 

In  explanation  of  the  terms  positive  and  negative,  it 
should  be  understood  that  electricity  inheres  in  all 
bodies.  The  tendency  to  develop  electricity  is  called  the 
potential  of  the  body.  The  earth,  being  an  unlimited 
reservoir  of  electricity,  is  taken  as  a  standard  in  regard 
to  the  comparative  potential  of  a  body.  Those  bodies 
from  which  electricity  flows  to  the  earth  we  call  posi- 
tive bodies,  and  bodies  which  draw  electricity  from  the 
earth  we  call  negative  bodies.  The  former  are  said  to  be 
of  a  Jiigh  potential,  the  latter  of  a  low  potential.  The 
terms  positive  and  negative  merely  express  the  difference 
of  the  potential;  for  all  bodies  are  relatively  positive  and 


GENERAL    THERAPEUTICS.  55 

negative.  When  we  say  that  a  body  is  charged  with 
positive  or  negative  electricity,  we  imply  the  condition  of 
positive  or  negative  potential  of  a  body.  This  may  be 
made  more  clear  if  we  compare  two  different  metals  to 
two  tanks  containing  water  at  different  levels.  If  the 
tanks  be  connected  by  a  tube,  the  water  at  a  high  level 
in  the  one  tank  will  flow  into  the  second  tank  containing 
water  at  a  lower  level.  If  a  third  tank  containing  water 
at  a  still  lower  level  be  connected  with  the  second  tank, 
then  the  water  between  these  two  tanks  will  flow  again. 
The  water  will  cease  to  flow  as  soon  as  it  has  reached  a 
common  level  in  all  the  tanks.  In  a  precisely  analo- 
gous manner  we  must  create  a  difference  of  potential 
between  two  points  if  we  wish  to  have  a  flow  of  electricity, 
and  likewise  the  current  of  electricity  ceases  when  an 
equilibrium  is  established  between  the  high  and  low 
potential.  Within  the  galvanic  cell  positive  electricity 
passes  from  the  zinc  plate  to  the  copper  or  carbon  plate^ 
and  outside  of  the  battery  the  current  passes  to  the  zinc 
in  completing  its  circuit.  It  is  due  to  the  latter  circum- 
stance that  the  terminal  of  the  connecting  wire  attached 
to  the  zinc  element  is  called  the  negative  pole. 

Faradism.  Faraday's  discovery  that  a  galvano-mag- 
netic  current  induces  new  currents  in  a  neighboring 
conductor,  has  been  utilized  in  the  construction  of  an 
apparatus  which  renders  such  "induction  currents'^ 
available  for  medical  use.  A  portable  faradic  battery 
consists  of  one  or  two  galvanic  cells  that  generate  the 
original  current.  A  coil  of  wire  wound  around  a  wooden 
cylinder  and  having  in  its  center  a  bundle  of  soft  iron 
rods  is   connected    at  one   end  with  the   cell    and  at  the. 


56  MA  N  UAL  OF  NER  V  0  US  DISEA  S  ES . 

other  end  with  an  automatic  interrupter.  This  inter- 
rupter is  an  ingenious  contrivance  by  which  the  "  make" 
and  "break"  of  the  current  is  effected.  It  consists  of  a 
spring  attached  by  its  lower  end  to  the  coil.  Its  free 
extremity  has  the  form  of  a  hammer  which  impinges 
upon  the  iron  core  of  the  coil  and  is  in  contact  with  a 
screw  that  connects  with  one  of  the  poles.  As  long  as 
the  current  generated  in  the  cell  is  not  interrupted,  this 
mechanism  is  at  rest,  but  as  soon  as  the  iron  core  becomes 
magnetized  it  attracts  the  hammer  and  the  circuit  is 
broken.  On  quickly  becoming  de  nagnetized,  the  ham- 
mer by  force  of  its  spring  flies  back  to  the  S2rew,  the 
circuit  being  thus  again  re-established.  The  successive 
closure  and  opening  of  the  circuit  generates  the  induction 
current  in  the  coil.  This  current  is  called  the  primary 
<:urrent.  A  second  coil  consisting  of  thinner  and  longer 
wire  surrounds  the  primary  coil,  but  is  not  otherwise 
connected  with  the  apparatus.  The  connecting  wire 
(rheophore)  to  which  the  electrodes  are  attached,  connect 
with  the  terminals  of  the  second  spiral.  The  current 
which  develops  in  this  second  coil  constitutes  the  second- 
ary  current.  This  current  is  the  one  usually  preferred  in 
medical  practice.  The  strength  of  the  current  is  regulated 
by  sliding  the  upper  coil  over  the  lower  to  the  required 
distance,  which  is  indicated  by  a  graduated  scale. 
Faradic  batteries  are  now  made  in  which  the  coils  are 
immovable,  the  strength  of  the  current  being  regulated 
by  a  draw  tube.  The  play  of  the  hammer  can  be  con- 
trolled by  the  finger  or  by  means  of  a  stud,  which  every 
good  battery  should  have. 

It  should  be  remarked  that  the  physiological  effects  of 


GENERAL    THERAPEUTICS.  57 

both    the   primary  and    secondary  currents    only  become 
manifest  with  the  break  of  the  original  current. 

Electro-motive  force.  The  work  which  a  definite  quan- 
tity of  electricity  can  perform  is  called  its  electro-motive 
force.  This  working  capacity  of  a  current  is  influenced 
by  the  resistance  which  the  current  meets  in  its  passage. 
There  are  two  such  resistances — the  one  essential  to  the 
battery  (fluid,  connecting  wires)  called  the  "internal 
resistance,"  and  the  other,  outside  of  the  battery  (the 
interposition  of  a  part  of  the  human  body)  called  the 
"external  resistance."  Ohm  laid  down  the  following  law 
for  the  determination  of  the  strength  of  electric  currents: 
The  strength  of  a  current  is  always  ^proportionate  to  the 
electro-motive  force  divided  by  the  resistance.  This  is  mathe- 
matics lly  represented  by  the  formula  C  =  r.  C  signifies 
the  current,  E  the  electro-motive  force  and  R  the  resist- 
ance. If  we  suppose  E  =  5  and  R  =  100,  then  C  =  t^o  =  2V. 
It  is  apparent  that  we  cannot  increase  the  strength  of  a 
current  by  merely  multiplying  the  number  of  the  elem^ts 
— since  for  each  increase  of  electro-motive  force  we  get  a 
proportionate  increase  of  resistance.  For  instance,  if  we 
use  two  elements,  our  formula  becomes  C  =1X0  ^  1 0  0  ~  2V 
i.  e.,  the  same  as  for  one,  and  obviously  with  a  like  result 
for  any  greater  number  of  elements.  We  obtain  a  differ- 
ent result  when  an  external  resistance  is  interposed, 
which  is  always  very  great  in  comparison  with  the 
internal  resistance.  This  occurs  in  practice  when  the 
human  body  forms  a  part  of  the  circuit.  In  such  a  case, 
giving  the  same  values  to  E  and  R  as  above,  let  us  call 
Ri  the  external  resistance  1000;  we  then  have  the  equa- 
tion C  =  ^^^j  and  substituting  values,  C 


58  iMA  N  UAL  OF  NER  VO  US  DIS  EA  SES . 

If  we  now  use  two  elements  we  get  C  =  loo+VJcTrrrr^^  ik 
the  strength  of  the  current  is  nearly  doubled,  for  the 
external  resistance  is  the  same  for  any  number  of  ele- 
ments as  it  is  for  one.  Practically,  the  minute  additions 
of  the  internal  resistance  may  be  entirely  neglected  in 
the  calculation  of  the  current  strength  when  the  external 
resistance  is  relatively  very  great. 

Measurement.  In  medical  practice  we  adopt  the  one- 
millionth  part  of  an  ampere  as  a  unit  of  measure  for 
the  current  strength,  and  call  it  a  milliampere.  The 
scale  of  galvanometers  is  now^  usually  divided  into 
milliamperes. 

Density.  The  strength  of  a  current  in  relation  to  a 
transverse  section  of  its  conducting  medium  is  caHed  the 
density  of  the  current.  This  means  that  the  current 
strength  is  in  proportion  to  the  quantity  of  electricity 
which,  in  a  given  moment  of  time,  passes  through  a 
sectional  area  of.  the  conducting  medium.  Suppose  an 
electric  current  be  conceived  to  consist  of  a  bundle  of 
parallel  rays  it  is  evident  that  the  smaller  the  diameter 
of  a  bundle  the  more  compact  will  be  the  rays,  and  the 
density  of  the  rays  will  increase  in  proportion.  The 
density  of  a  current  is  therefore  the  strongest  in  the  con- 
ducting wires,  less  strong  in  the  electrodes,  and  least  in 
the  lines  of  distribution  through  the  human  body. 
Among  the  rays  0/  the  current  in  its  passage,  the  strongest 
is  the  straight  one  between  the  points  of  application,  for  it 
takes  the  shortest  route  and  meets  with  the  least  resistance. 
All  the  other  rays  from  pole  to  pole  decrease  in  strength 
in  proportion  to  the  length  of  their  circuitous  course, 
and  the  cumulative  resistance  they  encounter.     If  it  is 


GENERAL    THERAPEUTICS.  59 

intended  to  excite  a  certain  part  of  the  body,  the  method 
of  conducting  the  current  must  be  such  that  its  greatest 
density  shall  act  upon  the  part. 


Fig. 13. 
ThJB  diagram  is  intended  to  illustrate  the  diffusion  of  the  cur- 
rent throughout  the  arm.  It  also  illustrates  the  greatest  density 
of  the  current  in  the  immediate  vicinity  of  both  electrodes  of  equal 
size,  which  are  placed  over  a  nerve  (ulnar).  The  inactive  rays  of 
the  current  are  marked  by  dotted  lines;  the  .shaded  parts  indicate 
the  regions  of  greatest  density. 

Polar  action.  A  contraction  is  the  visible  effect  of  the 
current  when  acting  upon  a  healthy  nerve  or  muscle,  and 
a  contraction  only  develops  at  the  moment  when  there  is 
a  make  or  a  break  of  the  current.  But  the  energy  and 
amplitude  of  contractions  are  also  influenced  by  the  par- 
ticular pole  with  which  the  closure  and  opening  of  the 
circuit  is  effected.  This  peculiarity  of  the  electrical 
phenomena  exhibited  in  normal  neuro-muscnlar  organs  is 
called  the  "  polar  action."  Examination  with  the  galvanic 
current  in  varying  the  experiment  with  currents  of  different 
strengths  exhibits  the  normal  laws  of  polar  action: 

a.  With  a  we,al:  current  the  first  perceptible  contraction 
occurs,  when  the  circuit  is  closed  with  the  kathode.    This 


60  MANUAL   OF  NEB  VOUS   DI S EASES. 

kathodal  closing  contraction  is  expressed  by  the  letters 
K  C  C  (sometimes  C  C  C  or  Ka  8  Z,  according  to  the 
German  notation). 

h.  A  medium  current  excites  a  strong  kathodal  closure 
contraction  (K  C  C^),  also  a  moderate  anodal  closure  con- 
trction  (A  C  C),  and  a  moderate  anodal  opening  contrac- 
tion (A  O  C). 

c.  A  strong  current  excites  a  tetanic  kathodal  closure  con- 
traction (K  C  C'*),  a-lso  a  strong  anodal  closure  contraction 
(A  C  C^),  a  strong  anodal  opening  contraction  (A  0  C^) 
and  a  perceptible  kathodal  opening  contr-^.ction  (K  0  C). 

It  will  be  observed  that  according  to  the  normal  laws 
of  polar  action  the  closure  contractions  appear  earlier 
than  the  opening  contractions,  and  that  there  is  a  regular 
order  of  polar  action  in  relation  to  the  appearance  of  the 
contractions.  The  formula  of  normal  polar  action  only 
holds  good  when  muscles  are  indirectly  acted  upon  by 
exciting  their  corresponding  motor  nerves  with  the  gal- 
vanic current.  The  direct  stimulation  of  muscles  is  only 
effected  by  closure  currents. 

Electrotonus.  Although  when  a  current  passes  uninter- 
ruptedly through  a  motor  nerve  or  muscle  no  visible 
effect  is  produced,  experiment  shows  that  a  change  occurs 
in  the  condition  of  the  nerve  during  this  apparent  quies- 
cence. This  change  consists  of  an  altered  irritability  of  the 
nerve.  Such  a  nerve  is]said  to  be  in  a  condition  of  electro- 
tonus. The  irritability  of  the  nerve  is  heightened  at  the 
point  of  contact  of  the  kathode  and  in  its  immediate 
vicinity  (katelectrotonus);  it  is  lowered  at  the  point  of 
contact  of  the  anode  and  in  its  vicinity  (anelectrotonus). 
From  this  circumstance  it  is  inferred  that  the  kathode  is 
the  stimulating  pole  and  the  anode  the  sedative  pole. 


GENERAL    THERAPEUTICS.  61 

The  conducting  power  of  organic  tissues.  The  distribu- 
tion of  the  current  in  the  human  body  is  influenced  by 
the  inequality  of  the  conducting  power  of  the  different 
tissues.  The  muscles  and  nerves  are  the  best  conductors. 
The  epidermis  opposes  the  greatest  resistance  to  the 
passage  of  the  current,  but  this  resistance  varies  in  differ- 
ent areas  of  the  cutaneous  surface,  as  seen  by  the  follow- 
ing table  according  to  the  investigations  of  Erb: 

Temples 40"" 

Cheeks 50° 

Side  of  the  neck 35° 

Shoulder-blade 30° 

Anterior  surface  of  thigh 3° 

Anterior  svirface  of  the  upper  arm 25° 

Popliteal  space 26° 

Palm  of  the  hand , 20° 

Effects  of  the  current  on  the  special  senses.  The  faradic 
current  barely  affects  the  special  senses,  but  they 
promptly  react  to  the  galvanic.  On  applying  a  weak 
current  to  the  temple  or  cheek  the  sensation  of  a  flash  of 
light  is  experienced.  When  a  closure  or  opening  current 
is  applied  to  the  ear,  a  whistling,  ringing  or  hissing  noise 
is  heard.  Stimulation  of  the  tongue  causes  a  peculiar 
metallic  taste  in  the  mouth.  The  sense  of  smell  does  not 
appear  to  be  influenced.  Galvanization  produces  a  peculiar 
stinging  or  burning  sensation  of  the  skin.  Faradization 
causes  a  feeling  of  tingUng.  Strong  currents  cause  pain 
and  spasmodic  rigidity  of  muscles. 

Electro-diagnosis.  Electric  examination  intends  to 
determine  the  existence  or  non-existence  of  quantitative 
and  qualitative  changes  of  the  excitability  of  nerves  and 
muscles.  Quantitative  changes  relate  to  energy  and  ampli- 
tude  of  contractions.       A    normal    electric    contraction 


62  MANUAL   OF  NERVOUS   DISEASES. 

develops  at  once  and  is  brief  and  vigorous.  Diminution 
of  the  electric  reaction  is  indicated  when  a  relatively 
strong  current  is  required  to  excite  a  contraction,  or  when 
the  contraction  develops  slowly  and  is  prolonged.  The 
strongest  current  fails  to  excite  a  contraction  in  complete 
loss  of  electric  reaction.  Morbid  increase  of  the  electric 
excitability  is  manifest  when  a  weak  current  elicits  an 
energetic  contraction  of  great  amplitude.  Qualitative 
changes  chiefly  relate  to  the  existence  of  abnormal  polar 
reaction.  A  diseased  nerve  or  muscle  may  react  to  a 
weak  current,  but  the  contractions  manifest  a  reversal  of 
the  normal  formula  of  polar  action.  Such  an  irregular 
order  of  the  electric  reaction  indicates  the  existence  of 
degenerative  changes  of  motor  nerves  or  muscles,  and  is 
therefore  called  the  reaction  of  degeneration  (R  D).  This 
condition  is  exhibited,  for  example,  when  the  sequence  of 
normal  polar  action  is  altered,  so  that  A  0  C  appears 
earlier  than  K  C  C,  or  when  K  0  C  is  too  promptly 
excited.  It  may  also  be  found  that  the  faradic  contrac- 
tility of  a  muscle  is  diminished  or  abolished,  while  the 
muscle  still  responds  to  the  galvanic  current  for  a  certain 
time,  and  even  with  increased  energy.  In  severe  cases 
of  atrophic  paralysis  exhibiting  R  D  a  gradual  diminu- 
tion of  the  galvanic  muscular  contractility  occurs  until  it 
is  finally  abolished.  It  is  remarkable  that  in  favorable 
cases  the  voluntary  power  of  the  affected  muscle  is 
restored  sooner  than  its  electric  excitability.  The  reason 
why  a  degenerated  muscle  reacts,  at  least  feebly,  to  the 
galvanic  current  and  not  to  the  faradic,  has  not  ^-et  been 
explained.  A  partial  reactioii  of  degeneration  is  some- 
times observed.  The  nerve  in  this  condition  retains  its 
electric  excitability  and  the  muscular  contractility  is 
normal,  but  the  direct  galvanic  excitability  of  the  muscle 


GENERAL    THERAPEUTICS 


6S 


is  increased  and  the  normal  sequence  of  polar  action  is 
altered.  This  form  of  degenerative  reaction  indicates 
anatomical  changes  in  the  muscles,  but  not  in  the  nerve. 
It  is  often  manifest  in  atrophic  paralysis. 

Motor  points.  To  facilitate  electric  examination  it  is 
very  advantageous  to  be  familiar  with  those  regions  on 
the  surface  of  the  body  where  nerves  are  accessible  to 
electrodes.  Stimulation  of  such  "motor  points"  excite  a 
number  of  muscles  to  which  a  nerve  trunk  or  a  large 
branch  is  distributed.  By  this  indirect  method  of  elec- 
trization deep  muscles  are  reached  by  the  current.  The 
annexed  figures,  showing  the  motor  points,  are  reproduced 
from  Ziemssen  and  Erb. 


MOTOR   POINTS 


M.  frontalis 


Upper  branch  of 
facial  nerve 

31.  orbic.  palpeb. 

Nasal  muscles 

M.  ziKornatici 

M.  orbic.  oris 

Middle  branch  of 

facial  nerve 

M.  levator  mcnti^ 

M.  quad,  menti    > 

M.  triang.  menti) 

Hypoglossal  nerve 
M.  platysm  niyoid 

Inferior  branch  of 
the  facial  nerve 

M.  omohvoides 


Region  of  the  cen- 
tral convolution 

Region  of  the  thir.d 
frontal  convolut- 
ion (Brocas) 

Upper   branch    of 

the  facial  nerve 
Trunk  of  facial 
nerve 


Inferior  branch  of 
facial  nerve 

M.  sterno  cleido- 
rnastoides. 

Accessory  nerve 


Phrenic  nerve    Supraclavicular  point    Brachial  plexus 

(Erb's  point),  M.  deltoid, 

biceps,  brachial  internus 

and  supinator  longus. 

FiJ.   14 


Branch  of  the  median  nerve 
for  the  pronator  teres 

Palmaris  longus 


Flexor  carpi  ulnaris 


Flexor  sublimis  diRltorutn 
(middle  and  ring  fingers) 

Ulnar  nerve 

Flexor  sublimis  digitornra 
(index  and  little  fingers; 

Deep  branch  of  the  ulnar 

nerve 

Palmaris  brevis 

Abductor  minimi  digitorum 

Flexor  brevis  minimi  digiti 


Lumbricalis  (2,  o  and  4) 


Supinator  longus  — . 

Extensor  carpi  radialis  ... 
longior 

Extensor  carpi  radialis    - 
brevior 

Extensor  communis  ) 
digitorum  ( 

Extensor  indicis  -- 
Extensor  indicis  and  extensor  — 
ossis  metacarpi  poUicis 

Extensor  ossis  meta-  " 
carpi  pollicis 

Extensor  primi  internodii  -■ 
pollicis 
Flexor  longus  pollicis    ' 


Dorsal  interossii 


•--    Flexoricarpi'radialis  ' 

—    Flexor  profundus  digitorum  , 

iM3i  am  '""3 

.„    Flexor  sublimis  digitorum 


Flexor  longus  pollicis 

"t ' """ 

•■■-■■■v- "  Abductor  pollicis 

\  --  Oppouens  pollicis 

•       Flexor  brevis  pollicis 

*     •         \  ■■"  Abductor  pollicis 

"*=■  ■   C^L^"'  Lumbricalis  (Isr) 


Extensor  car]>i  ulnaris 
Extensor  minimi  digiti 

Extensorjiudicis 


Extensor  secundi  internodii 
pollicis 


Abductor  minimi  digiti 
Dorsal  interosseus'.(4) 


(64  J 


Fk;.   10 


GENERAL   THERAPEUTICS. 


65 


Inferior  gluteal  nerve 
for  glutius  maximus 

Great  sciatic  nerve 

Long  head  of  biceps 

Short  head  of  biceps 


.*:/ 


Abductor  magnus 

Semitendonosus 

Semimembranosus 


Posterior  tibial  nerve 
Peroneal  nerve 

Gastrocuemeus 

(external  head) 

Soleus 


Fig.  17 


Gastrocn  emeus 
(internal  head) 


Anterior  crural  nerve 

Obdurator  nerve 

Sartorius 

Abductor  longus 

Branch  of  crural  nerve  to 

quadriceps  extensor  feinoris 

Crureus 

Branch  of  crural  nerve 
to  vastus  externus 


Tensor  faciarfemoris  (branch 
of  superior^^luteal  nerve)! 

Tensor  facial  femoris  (branch 

of  craral  nerve) 
Rectus  femoris 


Vastus  externus 
Vastus  externus 


Fig.  18 


Peroneus longus ' 
Tibialis  anticus  • 


I'LTuiical  uerve 
,^  Ga.strocnemeus 

"'"°"'      E.xtL'rnal  communis 
digitorum  longus 


Pi-roneias  brevis 
Soleus 


Flexor  loDgus  pollicis 


Extensor  longus  pollicis 


Branch  of  peroneal  nerve  for >.  \ 

extensor  brevis  digitorum  /        ^  'A— Extensor  brevis  digitorum 


Dorsal  iuteross 


"l;; 


"'M^' 


Fi(.    10 


Gastrocnemeus 
(internal  head) 

Soleus— 


Flexor  communis 
digitorum  longus 


Posterior  tibial  nerve. — 


Abductor  pollicis  — 


—  Abductor  minimi  diglti 


(66) 


Fig.  20 


GENERAL    THERAPEUTICS.  67 

Methods  of  electric  examination.  In  forming  a  correct 
judgment  of  the  comparative  reaction  of  symmetrical 
muscles  it  is  necessary  to  choose  a  current  of  the  same 
strength  and  electrodes  of  the  same  size.  Symmetrical 
points  of  the  two  sides  must  be  tested  in  every  separate 
examination.  The  sponges  should  be  well  soaked  in 
warm  water  (to  which  salt  may  be  added),  and  the  skin 
thoroughly  moistened  with  the  same  solution.  Inter- 
ruptions, when  the  galvanic  battery  is  used,  are  made 
with  a  special  interruptor.  It  consists  of  an  electrode 
handle  furnished  with  a  spring  which  is  connected  with  a 
stud.  Pressure  with  the  finger  on  the  stud  controls  the 
make  and  break  of  the  circuit.  The  strength  of  the 
faradic  current  is  measured  by  the  sliding  scale  or  draAV- 
tube.  The  secondary  current  is  preferred  in  examina- 
tions. In  testing  with  the  galvanic  current  the  number 
of  cells  in  use  must  be  noted.  The  galvanometer  is,  how- 
ever, a  more  exact  means  of  measurement.  Small  or 
"  fine"  electrodes  are  selected  for  exciting  motor  points 
and  small  muscles. 

In  examining  with  the  faradic  current  it  should  be 
noticed  what  minimum  strength  of  the  current  is 
requisite  to  cause  a  contraction  of  each  of  the  symmet- 
rical muscles.  The  suspected  muscle  may  be  as  excit- 
able as  its  fellow,  or  require  an  increased  current  strength; 
or  its  electric  contractility  may  be  diminished  in  energy, 
or  abolished.  Examination  with  the  galvanic  current 
determines  similar  conditions  of  the  muscular  contrac- 
tility, and  especially  the  signs  of  the  reaction  of  degener- 
ation. 

Electrotherapy.  Little  of  a  positive  character  can  be 
advanced  in  explanation  of  the  modus  opei'andi  of  elec- 


C8  MANUAL  OF  NERVOUS  DISEASES. 

tricity  as  a  therapeutical  agent.  Its  reputation  rests  for 
the  most  part  on  the  teachings  of  experience.  We  know 
that  certain  pathological  conditions  are  modified  under 
the  influence  of  electricity  in  some  undetermined  man- 
ner. The  peculiar  stimulant  effect  of  the  current  on 
nerve  or  muscle  is  of  great  value  in  paralytic  affections. 
It  is  supposed  that  in  cases  where  electricity  exerts  a 
beneficial  influence  on  pathological  changes,  it  is  by  a 
process  of  molecular  or  chemical  action.  When  morbid 
exudations  tend  to  be  absorbed  and  removed  through  the 
effects  of  the  current  it  maybe  conceived  that  an  osmotic 
process  has  been  developed  among  the  organic  cells.  The 
palliative  influence  of  the  current  in  hyperaesthesia,  neu- 
ralgia and  spasm  is  perhaps  to  be  attributed  to  its 
anelectrctonic  effect.  Experiments  tend  to  show  that 
electric  excitation  may  act  beneficially  by  exciting  reflex 
action. 

Methods  of  using  the  current.  A  stabile  current  means 
the  application  of  electricity  when  no  contraction  is 
intended  to  be  excited.  The  electrodes  in  this  method 
are  held  immovable  upon  the  part.  By  alabile  current  is 
understood  a  more  active  influence  of  the  current.  For 
this  purpose  one  of  the  electrodes  remains  in  contact  with 
a  part  of  the  body  and  with  the  other  the  muscle  is  dabbed 
or  stroked.  Energetic  contractions  are  caused  by  successive 
closures  and  openings  of  the  circuit  with  the  interrupter. 
An  increase  of  the  strength  of  the  continuous  current  with- 
out adding  to  the  number  of  cells  is  accomplished  by 
occasional  reversals  of  the  poles  during  the  sitting  (Vol- 
taic alternatives).  Stimulation  of  the  skin  is  best  done 
with  the  farad ic  brush. 


GENERAL    THERAPEUTICS.  69 

Position  of  the  electrodes.  The  following  rules  in  regard 
to  the  position  and  size  of  the  electrodes  are  of  practical 
importance: 

1.  When  it  is  desired  to  concentrate  a  current  on  a 
large  structure  near  the  surface,  botk  electrodes  should  be 
of  a  medium  size  and  placed  upon  it  near  to  each  other, 
and  be  successive!}^  applied  to  all  of  its  parts.  This 
method  is  suited  to  large  muscles,  as  the  deltoid,  the 
gluteus,  vastus  internus,  etc. 

2.  When  it  is  intended  to  send  a  current  to  an  elon- 
gated structure,  such  as  the  spinal  cord,  it  is  advisable  to 
select  two  very  large  electrodes,  and  to  place  them  wide 
apart  over  the  region  of  the  affected  organ  so  that  the. 
rays  of  the  current  may  include  a  part  of  it. 

3.  Deep  seated  structures  may  be  reached  by  the  cur- 
rent when  two  large  electrodes  are  placed  opposite  each 
other  so  that  some  rays  of  the  current  may  permeate  the 
diseased  part  of  the  organ.  This  method  is  adopted  for 
electrizing  circumscribed  lesion  of  the  brain  and  diseased 
joints. 

4.  If  it  be  desired  to  direct  the  current  to  a  particular 
part  by  the  polar  method  a  small  electrode  is  selected 
which  is  then  called  the  "  active  electrode."  The  other 
electrode  of  a  larger  size,  called  the  "indifferent  electrode," 
is  applied  to  a  remote  part,  usually  the  nape  of  the  neck 
or  the  knee  cap. 

The  direction  method.  As  this  method  of  electrization 
is  advocated  by  eminent  observers  it  is  proper  to  refer  to 
it  here.  A  current  is  said  to  be  descending  when  it  passes 
from  the  center  to  the  periphery,  namely  when  the 
kathode  is  nearest  to  the  muscle,  and  conversely,  it  is  an 
ascending  current  when  it  passes  from  the  periphery  to 


70  MANUAL  OF  NERVOUS  DISEASES. 

the  center,  the  anode  being  then  nearest  to  the  muscle. 
The  majority  of  electricians  prefer  the  polar  method, 
which  certainly  has  superior  advantages. 


Fig.  21. 

Fig.  21  is  intended  to  show  the  necessity  of  placing  tlie  two 
electrodes  sufficiently  apaitto  allow  the  current  to  reach  the  organ 
(spinal  cord)  when  it  lies  at  a  certain  depth  below  tlie  surface. 

F!g.  22  shows  the  greatest  current  density  by  the  full  lines.  The 
dotted  lines  repre.^ent  the  inactive  currents.  This  figure  aL-o 
shows  the  greatest  current  density  at  the  small  active  electrode 
whicli  is  indicated  by  the  darker  shading  .of  the  lines. 

General  galvanization  is  practiced  for  the  purpose  of 
influencing  the  nerve  centers.  The  positive  pole  is  suc- 
cessively passed  from  the  vertex  and  forehead  down  the 


GENERAL    THERAPEUTICS.  71 

whole  length  of  the  vertebral  column.  The  negative  T)ole 
is  applied  to  the  epigastirum.  A  sitting  should  at  least 
occupy  fifteen  minutes.  General  galvanization  is  recom- 
mended in  the  treatment  of  insomnia,  neurasthenia  and 
various  functional  affections  of  the  nervous  system. 

General  faradization.  The  patient  in  this  method  is 
seated  on  a  low  chair,  his  feet  resling  on  an  electrode  of 
suitable  size  which  is  connected  with  one  of  the  poles  of 
the  faradic  battery.  With  the  other  electrode,  mounted 
with  a  large  sponge,  the  operator  electrizes  the  whole  sur- 
face of  the  body  from  head  to  foot,  care  being  taken  to 
adjust  the  strength  of  the  current  to  the  varying  sensi- 
tiveness of  the  different  parts  of  the  body.  An  applica- 
tion should  occupy  about  twenty  minutes.  General 
faradization  has  a  refreshing  efft  ct  in  muscular  weakness. 

The  electric  hath  is  a  mode  of  general  faradization.  One 
of  the  poles  of  a  strong  induction  current  is  placed  in  the 
bathtub  in  which  the  patient  is  immersed  to  above  his 
shoulders.  The  operator  faradizes  the  body  with  the 
other  pole,  which  should  be  mounted  with  a  large  sponge. 

The  electric  hand.  This  method  is  adopted  for  stimu- 
lating the  face  of  children  and  timid  persons.  One 
sponge  is  held  by  the  patient,  the  other  by  the  operator. 
The  latter  applies  the  palm  or  fingers  of  his  free  hand  to 
the  well-dried  skin  of  the  patient.  Dusting  the  face  with 
toilet  powder  mitigates  the  unpleasantness  of  the  appli- 
cation. 

Practical  rides.  An  overdose  of  electricity  should  be 
avoided.  There  is  no  better  way  of  becoming  familiar 
with  the  different  strengths  of  the  current  than  to  prac- 
tice on  one's  self.     A  good  way  of  judging  the  intensity 


12  MANUAL  OF  NERVOUS   DISEASES. 

of  the  current  is  to  apply  one  of  the  electrodes  to  the  ball 
of  the  thumb.  To  prevent  the  pain  which  is  caused  in 
using  a  strong  galvanic  current,  it  is  advisable  to  switch 
in  the  desired  number  of  elements,  a  few  at  a  time,  and 
to  exclude  them  in  the  same  manner  before  removing  the 
sponges.  A  firm  steady  pressure  on  the  electrodes  pro- 
duces less  pain  than  holding  them  lightly.  Dry  sponges 
or  the  uncovered  disks,  and,  better  still,  the  electric 
brush  should  be  used  in  anaesthesia.  Wet  sponges  must 
always  be  used  in  electrizing  motor  nerves  and  muscles. 
Daily  sittings  are  required  where  the  cumulative  effect 
of  the  stimulation  is  desired.  The  duration  of  a  sitting 
varies  according  to  circumstances  from  two  to  fifteen 
minutes.  Batteries  require  constant  care  to  keep  them 
in  good  working  order.  In  most  instances  when  an 
induction  apparatus  loses  its  force  it  is  due  to  rust  which 
collects  on  the  hammer  or  to  some  flaw  in  the  conducting 
wires.     The  fluid  requires  frequent  renewal. 

Friction^  massage, tapotement .  The  method  of  rubbing  and 
kneeding  the  skin  and  subjacent  muscles  is  much  adopted 
in  the  treatment  of  nervous  disorders.  This  procedure, 
technically  called  massage,  takes  up  much  time,  and  to 
carry  it  out  effectually  requires  considerable  expertness. 
Another  method  of  practicing  massage  consists  in  ham- 
mering the  muscles.  For  this  purpose  the  inferior  edges 
of  the  hands  may  be  used  after  the  manner  of  meat  chop- 
pers. A  more  elegant  and  efficient  way  of  practicing 
tapotement  is  to  tap  the  part  with  India  rubber  balls  or 
cylinders  fastened  to  a  wooden  liandle.  The  percussion 
hammer  is  well  adapted  for  use  on  superficial  nerves  and 
the  small  muscles  of  the  face. 


CHAPTER   IV. 
DISEASES  OF  THE  NERYOUS  SYSTEM. 

Diseases  of  Peripheral   Nerves. 
NEURALGIA. 

Pathology.  There  are  sufficient  reasons  to  consider 
neuralgia  an  independent  disease.  Although  pain  is 
always  due  to  a  morbid  condition  of  some  part  of  the  sen- 
sory apparatus,  yet  the  pain  of  neuralgia  cannot  be 
referred  to  a  known  pathological  change  of  the  affected 
nerve.  Probably  the  anatomical  alteration  is  sometimes 
of  the  nature  of  a  congestion  or  slight  inflammation  of 
the  nerve  sheath,  some\>hat  of  the  character  of  a  neu- 
ritis. In  the  greater  number  of  cases  we  can  only  con- 
ceive of  the  existence  of  a  peculiar  morbid  sensibility  of 
certain  nerves  which  is  intensified  by  a  source  of  irrita- 
tion. Clinically  neuralgia  may  be  defined  to  imply  the 
spontaneous  occurrence  of  paroxysms  of  pain  of  great 
severity,  limited  to  the  course  of  a  nerve  and  frequently 
associated  with  motor  and  vaso-motor  symptoms. 

Etiology.  In  many  cases  of  neuralgia  we  recognize 
abnormal  influences  and  conditions  that  act  as  predis- 
posing or  exciting  causes.  The  predisposing  causes 
include  1.  Heredity.  This  is  an  important  etiological 
factor  as  shown  by  the  frequent  occurrence  of  allied  neu- 

(73) 


7^  MA  N  UA  L   OF  KER  V  DCS   DIS  EA  SES . 

roses  in  members  of  the  same  family,  such  as  hysteria, 
neurasthenia,  epilepsy,  etc.  A  neuropathic  tendency  dis- 
posing to  the  development  of  neuralgia  may  also  be  fairly 
presumed  to  exist  in  individuals  free  from  hereditary  influ- 
ence. 2.  Age  exerts  a  marked  influence.  Neuralgia  usu- 
ally develops  between  the  ages  of  twenty  and  forty,  which 
includes  the  period  of  life  when  the  general  nervous  sys- 
tem is  most  actively  engaged.  Children  of  a  tender  age 
and  persons  advanced  in  life  rarely  sufl'er  from  neuralgia, 
but  elderly  people  are  sometimes  subject  to  a  terrible 
form  of  this  affection  (epileptiform  neuralgia.)  8.  Ser. 
Females  are  more  frequently  attacked  than  men.  Preg- 
nancy and  the  climacteric  period  especially  dispose 
women  to  neuralgia.  3.  Constitutional  conditions.  Gen- 
eral anaemia  and  the  chlorotic  diathesis  often  act  as  pre- 
disposing causes.  The  impoverished  state  of  the  blood 
and  the  consequent  mal-nutrition  lessen  resistance  to 
the  obnoxious  influences  that  favor  the  development  of 
neuralgia. 

Among  the  exciting  causes  of  neuralgia  are  included:  1, 
Cold.  Neuralgic  attacks  are  often  traceable  to  the  direct 
effects  of  exposure  to  draughts  of  cold  air  or  living  in 
damp  cellars.  2.  Traumatic  Sind  a nalagous  causes,  includ- 
ing injury  to  superficial  nerves  from  contusion  and  lacer- 
ation, or  irritation  from  a  contiguous  tumor,  aneurism, 
necrosed  bones  and  the  contraction  of  cicatrices.  3. 
Malarial  influences.  The  periodical  type  of  neuralgia  is 
usually  but  not  always  of  malarial  origin.  4.  Toxic 
causes.  The  most  frequent  sources  of  neuralgia  from 
these  causes  are  chronic  lead  and  arsenical  poisoning.  5. 
Syphilis.  The  nocturnal  pains  in  syphilis  may  be  of  a 
purely  neuralgic  character.     6.  ^' Reflex  neuralgia.'''     The 


D  IS  EA  SES   OF   THE  NER  VO  US  S  YS  T  E  M.         75 

frequent  connection  of  neuralgia  with  disease  of  remote 
organs,  more  especially  with  uterine  and  ovarian  trouble? 
is  a  common  observation.  If  this  form  of  neuralgia  as  is 
supposed  is  of  a  reflex  character,  it  is  difficult  to  under- 
stand the  connection.  Finally  neuralgia  is  often  asso- 
ciated with  diabetes  mellitus,  gout  and  pulmonary 
phthisis. 

General  Symptomati  logy  of  neuralgia.     The  essential  charac- 

ers  of  neuralgia  have  already  been  described.  The 
onset  of  an  attack  may  be  sudden,  but  premonitory 
symptoms  are  often  noticed  consisting  of  a  sensation  of 
pricking,  furriness  or  coldness  in  the  area  to  which  the 
affected  nerve  is  distributed.  Usually  the  pain  begins  with 
twinges  in  the  course  of  the  nerv-e  that  soon  assume  great 
intensity  with  variable  intermissions.  The  pain  is  of 
lancinating,  darting,  tearing  or  burning  character.  The 
paroxysms  of  pain  greatly  vary  in  violence  and  duration. 
There  are  patients  who  have  only  one  attack  or  several  at 
long  intervals.  Others  suffer  for  a  prolonged  period  with 
numerous  attacks  in  rapid  succession,  always  affecting 
a  particular  nerve  or  one  of  its  branches. 

Painful  points.  The  pain  often  affects  with  aggravated 
intensity  certain  points  in  the  path  of  the  nerve.  These 
puncta  dolorosa  are  recognized  by  passing  the  finger  along 
the  course  of  the  nerve  and  exerting  some  pressure  which 
causes  a  feeling  of  soreness  even  during  the  intermissions 
of  the  paroxysms.  They  are  not  always  present,  but 
usually  they  are  found  in  parts  where  the  painful  nerves 
pass  through  bony  canals  or  penetrate  the  fasciae  of  mus- 
cles. It  is  not  unusual  for  the  pain  to  radiate  to  other 
twigs  of  the  same  nerve.     Symmetrical   nerves  or  even 


70  MA  X  UAL   O  F  NER  V  0  US  DISEA  S  ES . 

nerves  in  remote  parts  of  the  body  are  sometimes  simul- 
taneously affected. 

Motor  irritation.  Symptoms  of  motor  irritation  fre- 
quently associated  with  neuralgia,  consist  of  twitching 
of  muscles  or  cramps  when  a  mixed  nerve  is  affected  as 
in  sciatica.  But  more  frequently  the  motor  disturbance 
is  of  a  reflex  nature.  This  is  well  examplified  in  the 
''convulsive  tic"  of  facial  muscles  in  trigeminal  neuralgia. 

Vaso-motor  symptoms  are  especially  often  observed  in 
neuralgia  of  the  face  and  head.  There  is  marked  pallor 
of  the  face  followed  by  redness  of  the  skin  and  of  the 
adjacent  mucous  membranes.  The  secretions  of  the  lach- 
rymal and  salivary  glands  are  increased. 

The  trophic  changes  of  neuralgia  consist  of  cutaneous 
eruptions  in  the  area  of  the  affected  nerve,  atrophy  of  the 
skin,  especially  of  the  fingers,  and  alteration  of  the  color 
of  the  hair  in  regions  corresponding  to  the  path  of  the 
painful  nerve. 

The  general  health  in  neuralgia  does  not  seem  to  suffer, 
but  in  long  standing  cases  an  excitable  condition  of  the 
nervous  system  develops  which  gives  rise  to  a  despondent 
state  of  the  mind. 

General  treatment  of  neuralgia,  It  is  of  prime  import- 
ance in  all  cases  of  neuralgia  to  search  for  its  possible 
cause.  A  morbid  tendency  whether  constitutional  or 
acquired  frequently  opposes  the  best  directed  efforts 
toward  permanent  cure.  To  guard  against  the  recurrence 
of  attacks,  those  prophylactic  and  therapeutical  measures 
are  indicnted  that  invigorate  the  general  system  and 
especially  tend  to  improve  the  condition  of  the  blood. 
Cases  that  admit  of  surgical  interference  promise  satis- 
factory results.  Thus  foreign  bodies  and  necrosed  bones  may 


DISEASES  OF   THE  NER  VOUS  SYSTEM.        77 

be  removed,  cicatrices  split  or  excised  and  neuromatous 
tumors  extirpated.  Neuralgia  occurring  at  regular  periods, 
whether  caused  by  malaria  or  other  morbific  influences 
are  often  successfully  treated  with  quinia  or  arsenic. 
Neuralgic  pain  of  syphilitic  origin  indicates  specific 
treatment.  Iron  has  a  deserved  reputation  in  all  varieties 
of  neuralgia  occurring  in  anaemic  individuals.  Codliver 
oil  and  malt  extract  may  also  be  given  with  advantage. 
Local  treatment  sometimes  suffices  in  very  mild  cases. 
Good  eff'ects  are  often  derived  from  the  various  forms  of 
sedative  and  stimulant  applications.  The  cantharidal  col- 
lodion is  certainly  preferable  when  in  cases  of  this  kind  a 
strong  counter-irritant  eff'ect  is  desirable.  This  vesci- 
cant  has  the  advantage  that  it  can  be  applied  with  a  brush 
to  any  part  of  the  surface. 

Electricity  is  often  of  great  service.  Diff'erent  methods 
of  using  the  current  may  be  adopted.  It  is  a  good  method 
to  apply  the  anode  of  a  weak  galvanic  current  to  the 
whole  extent  of  the  aff'ected  nerve,  or  to  select  the  painful 
points.  The  strength  of  the  current  may  be  gradually 
increased.  Variations  of  the  current  strength  during  a 
sitting,  or  interruptions  should  be  avoided.  In  neuralgia 
of  large  nerve  trunks  the  anode  of  a  descending  stable 
current  should  be  applied  either  to  the  center  of  the 
nerve  or  to  the  corresponding  region  of  the  vertebral 
column,  and  the  kathods  to  an  indifferent  peripheral  point. 
Sometimes  the  interrupted  current  gives  good  results 
when  applied  Avith  the  faradic  brush  in  the  form  of  a 
counter-irritant.  Duchenne  saw  good  effects  when  the 
brush  was  applied  at  some  distance  from  the  painful 
part. 


78  MAIS  UAL   OF  NERVOUS  DISEASES. 

Subcutaneous  injections  of  morphia  give  such  instan- 
taneous rehef  even  in  the  severest  forms  of  neuralgia  that 
patients  are  apt  to  demand  a  frequent  repetition  of  the 
remedy. 

Nerve-stretching  or  neurectomy  is  the  last  resort  in  des- 
perate cases.     The  relief  is  sometimes  permanent. 

Among  the  numerous  empirical  remedies  in  vogue  for 
the  cure  of  neuralgia,  there  are  undoubtedly  some  that 
do  not  owe  their  reputation  to  mere  coincidence.  Arsenic 
is  one  of  them  and  should  have  a  fair  trial  in  obstinate 
cases.  Turpentine  in  large  doses  is  an  old  remedy  in 
neuralgia.     Strychnia  is  sometimes  useful. 

THE  DIFFERENT  FORMS  OF  NEURALGIA. 

Neuralgia  of  the  Trigeminus. 

Etiology.  This  is  the  most  frequent  of  all  the  forms  of 
neuralgia.  On  taking  a  glance  at  the  distribution  of  this 
nerve  it  is  observed  that  its  main  divisions  and  branches 
pass  through  many  openings  of  the  cranial  bones  where 
they  are  readily  subject  to  pressure  and  irritation  from 
various  causes.  The  mild  type  of  facial  neuralgia  is 
usually  caused  by  atmospheric  or  malarial  influences. 
The  "brow  ache"  is  said  to  be  very  common  in  malarial 
districts.  Draughts  of  cold  air  give  rise  to  the  so-called 
''rheumatic"  form  of  trigeminal  neuralgia.  Search  should 
be  made  in  neuralgia  of  the  head  for  decayed  or  filled 
teeth  or  a  crowded  wisdom  tooth.  Affections  of  the  eyes, 
ears  and  nose  are  well  known  to  be  often  attended  by 
facial  neuralgia.  In  many  cases  of  obscure  origin,  consti- 
tutional causes  may  be  suspected. ' 


DISEASES  OF  THE  NERVOUS  SYSTEM.        79 

Clinical  History.  The  pain  in  severe  cases  of  trigeminal 
neuralgia  is  extremely  violent.  Patients  can  hardly  find 
words  enough  to  express  their  suffering.  Sometimes  the 
slightest  physical  exertion,  such  as  washing  the  face, 
talking,  masticating,  or  a  temporary  mental  excitement 
suffices  to  bring  on  an  attack.  Various  sensations  like 
a  feeling  of  pulling  or  dragging  the  skin  precede  the 
pain.  Some  patients  frantically  rub  the  face  with  the 
hand,  which  seems  to  give  them  relief.  The  pain  is 
not  always  confined  to  the  part  of  the  face  where  it 
commenced,  but  frequently  shoots  towards  the  occiput, 
and  sometimes  to  the  region  of  the  shoulder  and  clavicle. 

Motor  Disturbances,  in  the  form  of  reflex  spasmodic 
movements,  are  especially  frequent  in  severe  trigeminal 
neuralgia.  The  twitching  of  the  facial  muscles  aff'ects 
the  forehead,  the  eye  and  corner  of  the  mouth  and  causes 
distortions  of  the  face  (tic  doloreux).  Vaso-motor  symp- 
toms, which  are  quite  common  in  severe  cases,  consist 
of  strong  pulsation  of  the  temporal  arteries  and  an 
increased  secretion  of  the  lachrymal  and  salivary  glands. 
Neuralgia  of  the  opthalmic  branch  is  sometimes  compli- 
cated with  herpes  zoster,  which,  if  it  aff'ect  the  eyeball, 
may  have  serious  consequences. 

The  most  constant  painful  points  in  the  distribution  of 
the  opthalmic  branch  are  found  in  the  regions  of  the 
supra-orbital  notch,  on  the  upper  eyelid,  and  the  parietal 
eminence.  In  the  superior  maxillary  there  is  a  focus  of 
pain  at  the  infraorbital  foramen  and  another  in  the  region 
of  the  malar  bone.     The  most  constant  painful  point  in 


80 


MANUAL  OF  NERVOUS  DISEASES 


the  distribution  of  the  inferior  maxillary  branch  is  at  the 
mental  foramen. 


Fig.  22.     V^,  V2,  V 


A    Region  of  the  anterior. 
P    Kegion  of  the  posterior  cer 

vical  nerve. 
C  iii    The  third  cervical  nerve 
So     Supraorbital  n. 
St    Supratrochlear  n. 
It    Infratrcchlear  n. 
1     Lacrimal  n. 


3,  First,  Second  and  Third  Branch  of  the 
Trigeminal  Nerve  (v). 

S  m    Subcuteneus  malar  n. 
at     Auriculo-temporal  n. 
b     buccinalis. 
m     Mental  n. 

o  ma  and  o  mi     Occipital  ma- 
jor and  minor  nerves, 
cs    Cervicalis  superficialis. 


Diagnosis.  A  careless  diagnosis  may  possibly  confound 
trigeminal  neuralgia  with  an  affection  of  the  skull,  nose  or 
jaw.  As  a  point  of  distinction  between  the  central  and  peri- 
pheral form  of  neuralgia  of  the  head  or  face,  it  should  be 
remembered  that  the  distribution  of  the  pain  in  the 
former  is  the  more  extensive. 

Prognosis.  Recent  cases,  especially  when  the  pain  is 
confined  to  a  small  nerve  twig,  generally  get  well  in  a  short 
time,  but  curative  treatment  is  not  encouraging  in  invet- 
erate cases  occurring  in  persons  advanced  in  life. 


DISEASES  OF  THE  NERVOUS   SYSTEM.        81 

Treatment.  A  thorough  examination  of  the  possible  local 
or  constitutional  cause  of  neuralgia  should  always  be  made. 
The  teeth  should  be  inspected.  A  crowded  wisdom  tooth 
or  an  old  stump  ma}^  require  removal.  Attention  should 
also  be  directed  to  the  condition  of  the  upper  nasal  pas- 
sages in  severe  pain  in  the  region  of  the  frontal  sinus. 
The  neuralgia,  from  disease  of  the  middle  ear,  requires 
local  treatment. 

Large  doses  of  quinia  are  indicated  in  the  periodical 
type  of  neuralgia.  The  same  remedy  sometimes  acts 
well  in  cases  of  irregular  paroxysms.  Arsenic  often  suc- 
ceeds ^\hen  quinia  fails.  This  remedy,  usually  given  in 
the  form  of  Fowler's  solution,  should  have  a  fair  trial  in 
obstinate  cases.  The  rheumatic  form  of  neuralgia  some- 
times yields  promptly  to  a  full  dose  of  salicylate  of  soda. 
The  fluid  extract  of  gelseminum  in  doses  from  10  to  20 
drops  every  hour,  is  highly  recommended  in  neuralgia  of 
the  dental  nerve.  The  remedy  is  to  be  omitted  if  relief 
does  not  follow  the  third  or  fourth  dose.  Morphia,  as 
may  be  expected,  gives  sometimes  instantaneous  relief  in 
even  the  severest  cases.  Mild  cases  are  often  cured  by 
one  injection.  Atropia  injections  are  indicated  in  very 
obstinate  cases.  A  syringe  full  of  warm  water  injected 
in  the  region  of  the  painful  nerve  is  said  to  answer  as  well 
as  a  small  dose  of  morphia.  Phenacetine  has  lately 
established  much  reputation  in  facial  neuralgia.  Aeon- 
ilia  has  been  known  to  give  surprisingly  good  results  in 
cases  which  had  baffled  other  remedies.  The  dose  is 
from  3-1^  to  j-i-o  grs. 

Narcotics  may  sometimes  be  avoided  in  mild  cases  by 
the  use  of  sedative  or  irritating  embrocations.  A  very 
good  application  consists  of  a  mixture  of  chloroform,  one 


82  M  A  y  C  A  L   (}F  X E R  V  0  U S  D 1 S  E A  S  E S . 

part  to  three  of  water.  A  piece  of  flannel  is  soaked  with 
the  mixture  and  applied  to  the  painful  part;  the  flannel 
should  be  covered  with  a  thick  cloth  to  prevent  rapid 
evaporation.  The  external  application  of  atropia  is  some- 
times successful.  (See  formula.)  The  veratria  ointment 
well  rubbed  in  until  it  produces  a  sensation  of  tingling  is 
often  of  benefit. 

In  very  obstinate  cases  one  is  tempted  to  try  many 
remedies  that  have  occasionally  been  found  of  service. 
Among  these  may  be  mentioned  croton  chloral,  nitrate  of 
amyl,  turpentine,  phosphorus,  strychnia,  chloride  of  gold. 

The  general  treatment  in  weak,  ana?mic  persons  includes 
rest,  a  generous  diet,  and  the  administration  of  iron,  cod 
liver  oil  and  malt  extract. 

Section  of  the  nerve  has  been  frequently  practised  with 
success  in  supraorbital  and  infraorbital  neuralgia.  The 
risk  of  the  operation  is  hardly  to  be  considered  in  des- 
perate cases. 

Occipital  Neuralgia. 

As  branches  of  the  upper  cervical  nerves  distributed  to 
the  lower  portion  of  the  cheek  and  the  supraclavicular 
region  are  often  simultaneously  involved  with  those  that 
go  to  the  occiput,  it  is  usual  to  speak  of  cervico-occipital 
neuralgia. 

Etiology.  A  very  frequent  exciting  cause  of  this  form  of 
neuralgia  is  exposure  to  drafts  of  cold  air  when  the  body 
is  overheated.  The  neuralgia  is  not  to  be  confounded 
with  pain  located  in  the  same  regions  from  caries  of  the 
vertebral  bones. 

Clinical  History.  Occipital  neuralgia  is  often  bilateral. 
Usually  the  pain  extends  from  the  back  of  the  head  to 


DISEASES  OF    THE  NERVOUS  SYSTEM.        S3 

the  vertex.  Sometimes  it  radiates  to  the  lower  jaw  and 
even  to  the  arm.  The  worst  pain,  when  both  sides  are 
affected,  is  felt  between  the  occipital  prominence  and  the 
mastoid  process.  The  least  movement  of  the  head  aggra- 
vates the  pain.  Paroxysms  of  great  severity  are  almost 
unbearable  if  they  are  of  unusual  duration. 

Vaso-motor  disturbances  are  not  uncommon  during  the 
greatest  violence  of  the  attack.  One  of  the  pupils  may 
be  contracted,  and  the  ear  abnormally  red  and  warm. 

The  neuralgia  is  sometimes  attended  by  stiffness  of  the 
neck  and  swelling  of  cervical  glands. 

The  most  constant  painful  points  are  found  in  the  nape 
of  the  neck  where  the  occipitalis  major  emerges,  and  one 
in  the  course  of  the  same  nerve  at  the  back  of  the  head. 

Treatment.  Local  treatment  often  suffices  in  a  mild  case. 
The  nape  of  the  neck  is  to  be  frequently  rubbed  with  an 
anodyne  liniment,  and  surrounded  by  cotton,  wool  or 
oakum.  Patients  find  much  relief  from  supporting  the 
head.  In  more  severe  cases,  blistering  the  nape  of  the 
neck  with  the  cantharidal  collodion  is  preferable.  A 
few  doses  of  the  salicylate  of  soda  sometimes  succeeds  in 
checking  the  repetition  of  attacks.  In  protracted  cases, 
very  good  results  are  sometimes  obtained  from  a  strong, 
constant  current  passed  for  ten  minutes  through  the 
mastoid  process.  Violent  paroxysms  of  pain  require 
morphia. 

Brachial  Neuralgia. 

Etiology.     The  cutaneous  distribution  of  the  ulnar,  the 

median  and  radial  nerves  which  collectively  come  from 

the  brachial  plexus,  may  either  be  affected  with  isolated 

or  combined  forms  of  neuralgia.   The  superficial  situation 


84  MA  X  UAL  0  F  NER  VOUS   DISEASES. 

of  these  nerves  exposes  them  to  direct  injury  and  rheu- 
matic influences. 

Clinical  History.  Generally  the  pain  in  brachial  neuralgia 
is  widely  distributed.  Sometimes  it  is  continuous  or 
comes  on  in  attacks  of  great  violence.  It  is  usually  worse 
during  the  night.  Movement  of  the  limb  aggravates  the 
pain.  Not  only  the  arm  but  also  the  shoulder  and  back 
are  often  affected  with  severe  shooting  pains.  Weir 
Mitchell  describes  a  form  of  this  neuralgia  ( causal gia) 
resulting  from  gunshot  wounds.  The  pain  is  of  an  intense 
burning  character. 

Among  the  most  constant  painful  points  are  1.  The 
radial  point  at  the  lower  outer  aspect  of  the  arm.  2.  A 
median  cephalic  point  at  the  bend  of  the  elbow.  3.  A 
shoulder  point  corresponding  to  the  emergence  of  the 
cutaneous  branches  of  the  circumflex. 

Adventitious  symptoms  of  a  vaso-motor  or  trophic 
character  are  sometimes  observed.  There  is  a  peculiar 
shining  atrophic  condition  of  the  fingers  (Glossy  fingers.) 
An  instructive  example  came  under  my  notice  at  the 
Baltimore  City  Hospital.  A  young  girl  presented  herself 
complaining  of  violent  pains  of  the  left  arm  in  the  region 
of  the  distribution  of  the  posterior,  superior  and  inferior 
subcutaneous  nerves.  The  arm  was  covered  on  this  part 
with  an  eruption  of  large  blebs.  On  the  outer  side  of  the 
bend  of  the  elbow  a  few  black  spots  were  seen  that  proved 
to  be  the  ends  of  rusty  sewing  needles.  The  girl  confessed 
afterwards  that  she  had  designedly  thrust  the  needles 
in  for  the  purpose  of  being  admitted  into  the  hospital. 

Treatment.  The  arm  should  be  kept  in  a  sling.  Mild 
cases  often  yield  to  sedative  or  stimulant  liniments,  but 
blistering  is  sometimes  necessary.     The  use  of  the  con- 


DISEASES  OF   THE  NERVOUS  SYSTEM.        85 

stant  current  gives  good  results  in  obstinate  cases.  A 
full  dose  of  salicylate  of  soda  may  be  found  of  service  in 
the  rheumatic  variety  of  the  neuralgia.  The  paroxysmal 
violence  of  the  pain  can  only  be  relieved  by  morphia. 

DoRso — Intercostal  Neuralgia. 

The  superficial  branches  of  the  seventh,  eighth  and 
ninth  pairs  of  dorsal  nerves  that  run  in  the  direction  of 
the  intercostal  spaces,  are  generally  affected  in  this  variety 
of  neuralgia. 

Etiology.  Intercostal  neuralgia  is  more  often  met  with 
in  women  than  in  men.  It  is  especially  common  in  fac- 
tory girls,  seamstresses,  milliners  and  nursing  women. 
Females  with  uterine  or  ovarian  trouble  are  very  prone  to 
suffer  from  it.  The  pain  usually  affects  the  left  side  of 
the  chest  and  is  often  associated  with  spinal  tenderness. 
It  should  be  remembered  that  severe  and  obstinate  side 
pain  attends  caries  of  the  vertebrae,  aneurism  of  the 
thoracic  aorta  and  cancer  of  the  mediastinum. 

Clinical  History.  The  pain  is  felt  along  the  distribu- 
tion of  the  intercostal  nerves,  but  quite  as  frequently  it  is 
fixed  at  a  point  below  the  mamma  or  in  the  region  of  the 
axilla.  Coughing,  sneezing  or  even  drawing  a  deep 
breath  aggravates  the  pain.  Herpes  Zoster  is  often  asso- 
ciated vfiih  this  form  of  neuralgia.  The  pain  frequently 
persists  after  the  disappearance  of  the  eruption.  Severe 
cases  of  intercostal  neuralgia  bear  some  resemblance  to 
angina  pectoris,  but  the  pain  is  less  severe  though  more  con- 
tinuous, and  all  the  other  symptoms  characteristic  of 
the  latter  affection  are  absent.  There  is  no  sensation  of 
constriction  of  the  chest,  no  embarrassment  of  respiration 
nor  tumultuous  action  of  the  heart.     Painful   points    are 


SJ  MAXUAL   OF  NERVOUS  DISEASES. 

found  in  the  regions  where  the  nerves  emerge  from  the 
intervertebral  foramen,  at  the  bend  of  the  ribs  and  near 
the  junction  of  the  costal  cartilages  and  the  sternum. 
The  course  of  intercostal  neuralgia  is  frequently  pro- 
tracted in  nervous  and  anaemic  females. 

Treatment.  In  recent  and  mild  cases  it  will  often  suffice 
to  apply  a  mustard  poultice,  and  if  the  pain  does  not 
soon  yield,  blistering  may  become  necessary.  The  use  of 
the  constant  current  is  a  good  resource  in  obstinate  cases. 
Speedy  relief  of  the  pain  is  obtained  from  morphia  injec- 
tions. 

^Iastouynia    (Irritable    Breast). 

This  special  form  of  intercostal  neuralgia  of  the  female 
breast  occurs  at  the  period  of  puberty,  and  generally  in 
nervous  and  anaemic  women,  but  it  often  develops  at  an 
advanced  age.  It  is  sometimes  caused  by  erosion  of  the 
nipples  during  lactation,  and  is  also  liable  to  appear  dur- 
ing pregnancy.  Small  nodules  are  often  found  in  the 
breast. 

The  breast  is  so  extremely  sensitive  to  the  touch  that 
even  the  pressure  of  the  clothes  becomes  unbearable.  The 
pain  is  either  continuous  or  occurs  in  paroxysms. 

Treatmsnt  is  unsatisfactory.  Many  cases  of  mastodynia 
last  for  years  and  appear  to  baffle  every  remedy.  Patients 
obtain  some  relief  from  a  suitable  bandage  that  supports 
the  breast.  Friction  with  chloroform  liniment  or  bella- 
donna ointment,  temporarily  mitigates  the  pain.  Elec- 
tricity is  occasionally  of  service.  The  anode  of  a  stabile 
constant  current  is  applied  to  the  mamma,  and  the 
kathode  to  the  spine.  The  question  of  amputating  the 
organ  arises  when  the  suffering  is  so  great  that  it  under- 
mines the  general  health. 


DISEASES  OF  THE  NERVOUS   SYSTEM.        87 

LuMBAK  Neuralgia. 

The  branches  of  the  lumbar  plexus  of  nerves  are  rela- 
tively seldom  affected  with  neuralgia.  The  implication 
of  the  anterior  cutaneous  branches  of  the  crural  nerve 
below  Poupart's  ligament,  constitutes  crural  neuralgia. 
The  pain  is  felt  in  the  inner  aspect  of  the  thigh  and 
extends  to  the  calf  and  foot.  Neuralgia  of  the  obturator 
nerve  deserves  particular  attention  as  it  is  usually  symp- 
tomatic of  strangulated  hernia  in  the  obturator  foramen. 

Diagnosis.  Lumbar  neuralgia  must  be  distinguished 
from  afifections  of  the  bones  and  joints  in  the  painful 
regions.  Lumbago  is  a  rheumatic  muscular  pain  and  is 
bilateral. 

Treatment  is  conducted  on  the  general  principles  that 
have  been  described. 

Sciatica. 

This  is  one  of  the  most  frequent  forms  of  neuralgial 
The  great  length  and  extensive  area  of  distribuiion  of 
the  sciatic  nerve  subjects  it  to  injurious  influences,  and 
besides,  the  sacral  plexus  is  often  involved  in  intrapelvic 
disease. 

Etiology.  Age  and  sex  appear  to  exert  some  influence 
on  the  causation  of  sciatica.  It  is  seen  most  frequently 
in  the  middle  period  of  life  and  is  moro  common  in  the 
male  than  the  female.  It  is  also  noteworthy  that  the 
right  leg  is  oftener  affected  than  the  left.  In  most 
instances  the  neuralgia  results  from  strain  or  the  com- 
bined effects  of  cold  and  dampness.  Certain  vocations 
requiring  a  constant  uncomfortable  sitting  posture  may 
also  give  rise  to  the  neuralgia.     Among  the  special  excit- 


SS  MANUAL   OF  NERVOUS  DISEASES. 

ing  causes  are  to  be  mentioned  the  gravid  uterus,  forceps 
delivery,  impacted  feces,  pelvic  tumor  or  inflammation 
and  psoas  abscess. 

Clinical  History.  The  pain  usually  begins  in  the  region  of 
sciatic  notch  and  gradually  extends  to  the  buttock,  the 
posterior  surface  of  the  thigh,  the  anterior  aspect  of  the 
leg  and  finally  to  the  calf  and  outer  border  of  the  foot. 
As  a  general  rule  the  whole  area  of  distribution  of  the 
great  sciatic  is  affected.  Paroxysms  of  violent  pain  which 
patients  describe  as  of  a  burning  and  lightening  character 
are  preceded  by  a  feeling  of  furriness  and  coldness  of  the 
limb.  Very  often  the  pain  becomes  continuous  and  is 
worse  at  night.  Flexion  of  the  limb  is  apt  to  bring  on  the 
pain,  and  hence  the  patient  adopts  a  peculiar  stitf  gait. 
The  concommitant  symptoms  include  tremor  and  reflex 
spasms  (f  the  calf  muscles  and  a  feeling  of  numbness 
and  tingling  of  the  skin. 

One  of  the  tender  points  corresponds  to  the  part  of  the 
trunk  of  the  nerve  between  the  great  trochanter  and  the 
tuber  ischii.  There  is  a  fibular  point  in  the  superficial 
course  of  the  peronial  nerve  and  another  at  the  malleolus. 

Course.  Recent  mild  cases  of  sciatica  readily  yield  to 
judicious  treatment,  and  even  chronic  cases  if  there  be  no 
irremovable  cause,  are  frequently  cured,  but  relapses  are 
common.  Some  degree  of  weakness  and  stiffness  of  the 
limb  often  persists  for  weeks  and  months  after  recovery. 

Diagnosis.  The  distinction  between  sciatica  and  lum- 
bago is  not  always  an  easy  matter.  The  pain  in  lumbago 
is  more  diffuse  and  generally  confined  to  the  buttock  and 
is  increased  bv  movement  and  pressure.  A  careful  exami- 
nation will  guard  against' the  error  of  confounding  sciatica 
with   hip-joint  disease.     The  real  cause  of  sciatica   may 


DISEASES  OF   THE  XERVOUS  SYSTEM.        89 

remain  concealed  for  a  long  time  if  there  exists  an 
abdominal  aneurism  or  intrapelvic  disease. 

Treatment.  Old  standing  cases  of  sciatica  which  resist 
ordinary  treatment  sometimes  yield  with  astonishing 
rapidity  when  the  true  cause  is  discovered  and  treated 
accordingly.  The  most  favorable  of  chronic  cases  are  those 
in  which  the  exciting  cause  is  removable,  such  as  habitual 
constipation,  haemorrhoids,  varicose  veins  and  tumor. 

In  sciatica  of  recent  date  it  is  of  the  first  importance 
that  the  patient  keep  in  bed.  Warm  applications  are 
very  grateful.  A  hot  vapor-bath  is  especially  of  service 
in  "rheumatic''  cases.  Such  a  bath  can  readily  be 
improvised  by  heating  bricks,  wrapping  them  in  wet 
woolen  cloths  and  placing  them  between  the  lower  limbs 
and  outside  of  them.  The  escape  of  the  steam  is  pre- 
vented by  a  thick  covering  of  blankets. 

Protracted  cases  often  yield  to  blistering.  A  good  plan 
is  to  cross  the  affected  part  of  the  nerve  with  small 
blisters  about  two  inches  apart. 

Sciatica  is  more  frequently  cur^d  by  the  electric  treat- 
ment than  any  other  form  of  neuralgia.  I  use  a  gradually 
increasing  constant  current.  The  anode  is  allowed  to 
rest  quietly  foriit  least  two  minutes  at  a  time  on  different 
parts  over  the  path  of  the  nerve,  and  the  kathode  is 
applied  to  the  back.  Painful  spots  are  preferred  for  the 
anodic  application. 

Internal  remedies  rarely  give  satisfaction.  Quinia  and 
salicylate  of  soda  may  occasionally  be  found  of  service. 
Strychnia  has  also  been  recommended.  Turpentine  in 
large  doses  is  an  old  remedy  in  sciatica.  If  iodide  of 
potassium  is  successful  in  an  inveterate  case  of  the 
neuralgia,    it  was    probably    of  syphilitic  origin.     After 


90  MANUAL  OF  NERVOUS   DISEASES. 

every  other  remedy  has  failed,  nerve-stretching  is  the 
last  resort  which  although  it  may  not  give  permanent 
relief,  is  nevertheless  a  justifiable  procedure. 

Neuralgia  of  the  Genitals. 

The  external  genital  organs  are  but  rarely  subject  to 
neuralgia.  Spermatic  neuralgia  or  "the  irritable  testi- 
cle" as  it  was  formerly  called,  demands  particular  atten- 
tion. It  is  marked  by  violent  paroxysms  of  pain, 
beginning  in  the  testicle  and  extending  to  the  spermatic 
cord.  During  an  attack,  the  testicle  retracts  and  is  very 
sensitive.  This  is  a  most  obstinate  and  harassing  species 
of  neuralgia,  little  amenable  even  to  palliative  treatment, 
and  resisting  narcotics  and  electricity.  Castration  appears 
to  offer  the  only  means  of  relief. 

Weir  Mitchell  has  described  "  a  neuralgia  anno- 
peronialis"  occurring  among  masturbators  and  smokers. 

Neuralgia  of  the  region  of  the  rectum  is  sometimes 
seen  in  persons  much  reduced  in  health,  especially  from 
malaria  cachexia.  Dr.  Neftel  of  New  York  saw  good 
results  from  the  use  of  the  constant  current  in  such  cases. 

COCCYGODYMA. 

This  affection  is  characterized  by  severe  pains  in  the 
coccygial  region.  It  is  aggravated  when  the  patient  sits 
or  walks,  and  during  defecation.  This  trouble  generally 
occurs  in  women,  and  is  probably  caused  by  strain  or 
injury  in  labor.  It  is  a  most  intractable  affection,  and 
the  removal  of  the  coccyx  has  been  resorted  to  with  good 
success.  Before  deciding  on  such  a  measure,  which  is 
only  advisable  in  a  desperate  case,  a  fair  trial  should  be 
given  to  faradization.  One  of  the  electrodes  is  introduced 
into  the  rectum,  and  the  other  is  applied  to  the  sacrum- 


DISEASES  OF   THE  NERVOUS  SYSTEM.        91 

Neuralgia  of  the  Joints. 
It  is  well  known  that  Sir  Benjamin  Brodie  first  directed 
attention  to  the  occurrence  of  a  painful  affection  of  joints 
in  hysterical  women.  Recently  the  subject  has  been 
studied  by  Esmarch,  whose  observations  convinced  him 
that  cases  of  this  kind  in  which  generally  the  hip  joint  is 
affected,  illustrate  the  existence  of  an  ''  articular  neurosis." 
The  painful  joint  is  exempt  from  gross  anatomical  change. 
Weir  Mitchell,  in  his  interesting  chapter  on  the  "  Mimicry 
of  Disease,"  refers  to  the  morbid  influence  of  concentrated 
attention  on  a  particular  part  of  the  body  on  account  of 
some  trivial  hurt.  Hysterical  patients  are  especially 
prone  to  the  development  of  a  neuritic  affection  from 
such  a  cause. 

A  case  in  point  came  under  my  observation.  The  patient,  a  young 
married  woman  fell  against  her  side,  which  greatly  alarmed  her,  and 
rendered  her  very  anxious  concerning  the  consequences.  A  few  weeks 
later  she  took  to  her  bed,  in  which  she  remained  for  eight  months.  I 
found  her  lying  in  the  position  which,  I  was  informed,  she  had 
assumed  from  the  beginning.  The  left  leg  was  extended  and  slightly 
rotated  inwards.  This  is  the  limb  that  gave  her  so  much  trouble  after 
the  fall.  She  described  to  me,  with  tears  in  her  eyes,  the  unbearable 
suffering  she  had  since  undergone.  She  begged  me  not  to  touch  the 
sore  limb,  as  the  pain  it  would  cause  was  unendurable.  The  slightest 
movement,  she  said,  the  merest  touch  of  the  hand,  would  give  her  the 
most  excruciating  pain.  Those  about  her  had  so  much  given  away  to 
her  entreaties  not  to  be  disturbed  that  they  neglected  to  attend  to  a 
very  bad  bed  sore  that  had  developed  in  the  sacral  region.  Her  mother 
had  given  up  housekeeping  so  as  to  be  constantly  with  her  daughter. 
I  observed  no  swelling  about  the  knee  or  hip  joint  where  the  patient 
located  the  pain.  She  appeared  to  be  somewhat  emaciated,  though  her 
appetite  was  fairly  good  and  she  got  sufficient  sleep.  An  attempt  to 
move  the  limb  was  out  of  question,  as  the  patient  vehemently  protested 
against  it,  and  would  not  listen  to  any  reasoning  or  persuasion.  I 
suspected  the  character  of  the  affection,  and  stated  my  opinion  to  the 
attending  physician      Of  course  we   could  not   come  to  any  definite 


9e  MA  X  UA  L   0  F  X ER  VO  US  BIS EA  S ES . 

decision  until  the  limb  was  more  thoroughly  examined.  The  patient 
absolutely  refused  to  take  an  anesthetic.  We  carried  out  a  conspiracy, 
with  the  help  of  the  mother  and  nurse,  and  removed  her  to  a  lounge 
amidst  her  loud  wailing  and  protestations.  After  the  bed  sore  was 
dressed,  I  succeeded  in  rotating  the  limb  with  considerable  ease,  and 
to  flex  the  knee  in  spite  of  the  cries  and  opposition  of  the  patient. 
There  was  now  no  room  for  doubt  that  the  leg  was  healthy,  barring 
the  neurosis  of  the  joints.  Galvinization  constituted  subsequently  the 
chief  treatment.  Gradually  the  patient  was  induced  by  coaxing  and 
occasional  Arm  language  to  allow  her  limb  to  be  handled  more  freely, 
and  to  make  a  few  steps  with  the  assistance  of  her  mother  and  nurse. 
By  and  by  she  learned  to  walk  on  crutches.  When  I  paid  her  my  last 
visit,  I  found  her  quite  well  and  walking  without  any  support. 

NEURITIS. 

EtiOlcgy.  Inflammation  of  peripheral  nerves  is  observed 
in  injury  from  gunshot  wounds,  laceration  and  contusion. 
Nerves  in  the  neighborhood  of  diseased  vertebrae  and 
joints  may  become  involved.  Neuritis  also  occurs  as  a 
rheumatic  or  a  syphilitic  affection,  but  often  no  cause 
can  be  assigned. 

Anatomical  Changes.  Generally  the  neurillema  and  nerve 
fibre  are  conjointly  affected.  The  nerve  appears  swollen, 
its  capillaries  are  enlarged  and  hemorrhagic  spots  are 
seen.  Disintegration  of  the  medullary  sheath  and 
nerve  fibre  develops  in  severe  cases.  Numerous  cellular 
elements  accumulate  in  the  neurillema,  which  is  grad- 
ually thickened  by  the  formation  of  connective  tissue, 
and  may  finally  lead  to  destruction  of  the  affected  nerve. 
An  ascending  interstitial  neuritis  sometimes  occurs  which 
starts  from  the  seat  of  the  lesion.  In  mild  cases  regene- 
ration of  the  nerve  takes  place-  Simultaneously  with 
the  degeneration  of  a  motor  nerve,  nutritive  changes  of 
the   corresponding    muscles    ensue    that  .causes  atrophy 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


9S 


This  atrophy  is  permanent  if  the  nerve  fibre   has  com- 
pletely degenerated. 


ac 


ac 


ac 

Fig.  24.  Fig.  25. 

Fig.  24.     Normal  Medullary  Nerve  Fibre.     (Ranvier.) 
Fig.  25.     Alteration  of  Nerve  Fibre  After  Section. 
ac     Axis  cylinder.  S     Strangulation  of  the  medullary 

e     Ranvier' s  nodes.  sheath, 

sch     Sheath  of  Schwan.  my     Masses  of  myalines. 

my     Masses  of  myeline.  n     Nucleus    detached    from    the 

sheath  of  Schwan. 


94  MA  NUAL  OF  NER  VO  US  D ISEA  S  ES . 

Clinical  History.  Considerable  febrile  excitement  marks 
the  onset  of  acute  neuritis.  Intense  pain  is  felt  in  the 
course  of  the  nerve  and  its  distribution.  The  parts  are 
exceedingly  painful  to  the  touch,  and  the  swollen  nerve 
can  be  felt  through  the  skin.  There  is  often  a  subjective 
sensation  of  numbness  of  the  afiected  part,  but  the  motor 
disturbance  that  finally  makes  its  appearance  is  of 
more  importance.  A  form  of  atrophic  paralysis  is  estab- 
lished after  the  subsidence  of  the  acute  symptoms.  The 
muscles  show  the  reaction  of  degeneration.  There  are 
mild  cases  which  do  not  advance  to  this  condition. 
Others  take  a  tedious  chronic  course,  with  eventual  loss 
of  function  of  the  part.  There  is  a  group  of  degenerative 
neuritis,  of  which  the  following  are  the  most  important. 

Multiple  Neuritis. 

This  form  of  neuritis  is  chiefly  observed  to  affect 
motor  nerves  of  the  limbs.  At  a  late  stage  of  the  inflam- 
mation this  process  extends  to  the  finest  nerve  filaments 
that  are  distributed  to  the  muscles.  The  nerve  fibres  are 
thickened  and  nodulated  in  different  places  (neuritis 
nodosa).  The  sarcolemma  is  increased  and  infiltrated 
with  fat.  This  morbid  alteration  does  not  extend  to  the 
nerve  roots.  Further  investigation  will  probably  disclose 
the  fact  that  multiple  neuritis  is  the  pathological  con- 
dition underlying  the  atrophic  paralysis  of  lead  and 
arsenic  poisoning. 

Symptoms  of  sensory  disturbance  occur  at  the  begin- 
ning, consisting  of  tearing  pain  in  the  extremities, 
especially  in  the  hands  and  feet  and  attended  by  parses- 
thetic  sensations  about  the  joints.  Motor  disturbances 
develop  next,  characterized  by  a  flaccid  condition  of  the 


DISEASES  OF  THE  NERVOUS  SYSTEM.        95 

muscles,  diminution  and  final  loss  of  the  electric  reaction, 
as  in  all  forms  of  peripheral  paralysis.  The  neuritis  in 
the  first  stage  is  marked  by  fever  and  violent  pains  in  the 
limbs.  Restoration  may  t&ke  place,  but  in  severe  cases 
an  atrophic  paralysis  develops. 

Alcoholic  Neuritis. 

Chronic  alcoholism  may  give  rise  to  forms  of  paralysis 
which  are  now  considered  to  be  dependent  on  the  develop- 
ment of  multiple  neuritis.  The  main  clinical  feature 
of  the  disease  is  atrophic  paralysis  of  the  inferior  extrem- 
ities. In  some  cases  additional  symptoms  appear  that 
bear  a  close  resemblance  to  sclerosis  of  the  posterior 
columns  of  the  spinal  cord.  The  disease  begins  with 
violent  tearing  pains  in  the  legs  and  sometimes  in  the 
arms.  Gradually,  an  uncertainty  of  the  gait  is  estab- 
lished. In  well-marked  cases  there  is  also  a  paretic  con- 
dition of  the  limbs.  The  affected  muscles  show  wasting 
and  abnormal  electric  reaction.  There  is  early  abolition 
of  the  patellar  reflex.  The  cutaneous  sensibility  is 
impaired.  It  is  evident  from  the  character  of  these  symp- 
toms that  their  resemblance  to  those  of  loco-motor  ataxia 
is  complete.  If,  however,  atrophic  paralysis  coexists, 
then  spinal  disease  is  excluded.  In  the  alcoholic  affec- 
tion there  is  generally  no  immobility  of  the  pupils;  the 
girdle  sensation  is  absent  and  there  is  no  irritation  of  the 
bladder. 

Treatment.  Causal  treatment  is  of  the  first  importance 
in  traumatic  neuritis.  The  antiseptic  treatment  is  indi- 
cated in  the  case  of  infectious  wounds.  Primary  acute 
neuritis  call  for  measures  to  subdue  the  inflammation. 
If  the  arm  is  affected  it  should   be  supported  in  a  sling. 


90  MA  X  UAL   OF  NEB  VO  US  D  IS  EA  SES . 

A  poultice  of  crushed  ice  is  very  grateful  to  the  patient. 
Salicylate  of  soda  may  be  given  from  the  beginning,  but 
to  allay  the  severity  of  the  pain,  morphia  is  often  required. 
The  patient  should  not  be  allowed  to  leave  the  bed  too 
early.  The  paralysis  of  chronic  neuritis  is  best  treated 
with  electricity.  The  following  method  may  be  adopted : 
The  kathode  of  a  strong  constant  current  is  placed  on  the 
vertebral  column  in  a  position  corresponding  to  the  near- 
est part  of  the  affected  nerve.  The  anode  is  applied  for 
five  minutes  daily  to  paralyzed  muscles.  The  interrupted 
current  is  also  useful.  This  treatment  may  be  advantage- 
ously assisted  by  massage  and  warm  baths. 

Neuromata. 

New  growths,  diff'ering  in  histological  structure,  develop 
in  nerves  as  they  do  in  other  organs.  True  neuromata 
consist  of  newly-formed  nerve  tissue;  false  neuromata  are 
fibromatous.  The  so-called  "painful  tubercle'' is  usually 
of  the  latter  species.  It  occurs  in  different  parts  of  the 
body,  and  can  often  be  felt  as  a  small  nodule  under  the 
skin.  True  neuromata  sometimes  develop  in  the  stump 
of  an  amputated  limb.  The  cause  of  these  growths  is 
unknowm.  In  some  individuals  a  numerous  crop  of 
little  nodules  scattered  over  the  whole  body  make  their 
appearance.  These  multiple  neuromata  do  not  give  rise 
to  symptoms. 

Many  cases  of  true  neuromata  are  attended  by  a  violent 
intractable  pain.  The  only  permanent  cure  is  their  extir- 
pation.    Temporary  relief  is  obtained  from  narcotics. 


CHAPTER  V. 

PERIPHERAL  PARALYSIS. 

Under  the  head  of  peripheral  paralysis,  in  contradis- 
tinction to  paralysis  of  cerebral  or  spinal  origin,  are 
included  those  individual  forms  of  motor  and  sensory 
paralysis,  which  result  from  injurj^  or  disease  of  peripheral 
nerves.  The  general  character  of  peripheral  paralysis 
may  be  summarized  as  follows: 

1.  Diminution  or  loss  of -muscular  power  in  conse- 
quence of  interruption  of  the  conducting  motor  path, 
limited  to  the  affected  nerve. 

2.  Impairment  or  abolition  of  sensation  in  injury  or 
disease  of  mixed  nerves.  The  disturbance  of  the  cutane- 
ous sensibility  is  usually  insignificant  and  is  often  absent. 

3.  Vaso-motor  and  trophic  disturbances,  especially 
atrophy  of  the  paralyzed  muscles,  arrested  growth  of 
bones,  affections  of  the  joints  and  changes  in  the  skin. 
The  latter  are  indicated  by  dilatation  of  the  superficial 
vessels,  local  elevation  of  the  temperature,  cyanosis  and 
coldness  of  the  surface. 

4.  Abnormal  condition  of  the  electric  excitability. 

Etiology.  In  reference  to  the  exciting  causes,  we  distin- 
guish the  traumatic,  the  rheumatic,  the  toxic  and  post- 
febrile forms  of  peripheral  paralysis.  The  traumatic 
variety  also  includes   the  paralysis  from  prolonged  com- 

7  (97) 


98  MA  y  UAL  OF  NERVOUS  BIS  EA  S  ES . 

pression  of  a  nerve,  as  may  occur  in  cases  where  the 
patient,  in  a  state  of  intoxication,  had  been  sleeping  on  a 
hard  substance,  with  his  arm  bent  behind  his  back. 
Tight  bandaging  and  ill-constructed  crutches  may  pro- 
duce a  similar  effect.  Paralysis  of  one  or  both  of  the 
upper  extremities  is  sometimes  caused  in  new  born  infants 
during  the  operation  of  version. 

Rheumatic  peripheral  paralysis  most  frequently  affects 
the  face,  and  less  frequently  one  of  the  limbs.  These 
parts  are  especially  exposed  to  rheumatic  influences. 

The  toxic  forms  of  paralysis  chiefly  include  lead  palsy 
and  arsenical  paralysis. 

Among  the  post-febrile  forms  of  peripheral  paralysis, 
the  one  of  greatest  practical  importance  is  diphtheric 
paralysis. 

Anatomical  Changes.  In  the  traumatic  form  of  paralysis 
and  probably  also  in  severe  cases  of  rheumatic  origin,  the 
anatomical  changes  are  of  the  nature  of  an  interstitial 
neuritis  with  a  tendency  to  undergo  the  process  of  degen- 
eration. There  are  other  forms  of  paralysis  usually  con- 
sidered to  be  of  a  peripheral  character,  whose  pathology 
has  not  yet  been  satisfactorily  determined. 

VARIETIES  OF  PERIPHERAL  PARALYSIS  ACCORDING 
TO  THEIR  DISTRIBUTION. 

Paralysis  of  the  Motor  Branch  of  the  Trigeminus. 

This  species  of  paralysis  is  very  rarely  of  local  origin. 
In  partial  paralysis  of  the  masticatory  muscles,  the  act  of 
deglutition  is  difficult.  In  complete  bilateral  paralysis, 
mastication  is  impossible.  The  jaw  hangs  down  and  the 
muscles  gradually  atrophy. 


PERIPHERAL    PARALYSIS.  99 

Treatment.  Galvanization  deserves  a  trial,  but  if  the 
paralysis  is  of  central  origin,  it  requires  causal  treatment. 

Facial  Paralysis. 

Etiology.  This  is  the  commonest  of  all  forms  of  peri- 
pheral paralysis.  The  causes  of  the  paralysis  in  their 
order  of  frequency  are:  1.  Exposure  to  drafts  of  cold 
air,  as  when  a  person  sits  near  an  open  window  in  a  rail- 
road car  on  a  cold,  windy  day.  This  is  the  rheumatic 
form  of  facial  paralysis.  2.  Disease  of  the  ear,  when 
the  facial  nerve  is  involved  in  its  passage  through  the 
Fallopian  canal.  3.  Disease  at  the  base  of  the  brain 
where  the  nerve  is  implicated  after  its  emergence  from 
the  brain.  Facial  paralysis  is  therefore  frequently 
observed  in  intercranial  syphilis,  and  is  often  associated 
with  paralysis  of  some  of  the  ocular  muscles.  4.  Swell- 
ing of  the  parotid  gland  or  its  removal  in  operations.  5. 
Forceps  delivery.  The  infant  is  often  unable  to  take  the 
breast.  In  very  mild  cases,  the  paralysis  may  only  be 
discovered  when  the  child  cries,  which  produces  distor- 
tion of  the  face. 

Clinical  History.  Facial  paralysis  is  easily  recognized  in 
consequence  of  the  immobility  of  the  muscles  of  expres- 
sion of  one  side  of  the  face.  On  the  paralyzed  side  no 
wrinkles  are  visible  on  the  forehead  when  the  patient 
attempts  to  frown.  The  eye  on  the  affected  side  cannot  be 
voluntarily  closed.  This  permits  the  entrance  of  dust 
which  may  cause  conjunctivitis.  The  labio-nasal  fold  is 
effaced;  the  ala  nasi  is  flattened;  the  cheek  "  hangs  "  and 
flaps  during  inspiration,  and  bulges  out  during  expiration. 
The  mouth  is  drawn  over  to  the  healthy  side;  this  becomes 
very  apparent  when  the  patient  speaks,  laughs  or  cries. 
He  finds  it  difficult  to  whistle,  blow  or  spit.     The  saliva 


100  MANUAL   OF  NERVOUS  DISEASES. 

escapes  from  the  half-opened  mouth.  Morsels  of  food 
lodge  between  the  gum  and  cheek,  and  mastication  is 
rendered  difficult  on  account  of  the  flaccidity  of  the 
cheek.  The  tears  run  down  the  face,  as  the  paralysis  of 
Horner's  muscle  prevents  their  escape  into  the  lachrymal 
canal.  Speech  is  indistinct  from  imperfect  movement  of 
the  lips.  Immobility  of  the  soft  palate  on  the  affected 
side  is  observed  in  so?iie  cases,  but  the  position  and  move- 
ments of  the  uvula  vary  too  much  in  the  healthy  condition 
for  this  S3^mptom  to  be  of  any  sigaiticance. 

Impairment  of  the  sense  of  taste  exists  in  cases  in 
which  the  chorda  tympani  nerve  is  imj^licated.  This 
nerve  accompanies  the  facial  for  a  short  distance,  and 
sends  gustatory  fibres  to  the  lingualis.  Dryness  of-  the 
mouth,  due  to  diminished  secretion  of  saliva,  is  depend- 
ent on  the  same  cause.  Disturbance  of  hearing  occurs 
where  the  paralysis  originates  from  aural  disease. 

The  abnormal  electric  reaction  in  facial  paralysis  is  of 
much  importance  in  regard  to  prognosis.  Erb  distin- 
guishes three  different  conditions  of  the  electric  excit- 
ability : 

1.  The  mild  form,  which  is  the  one  most  commonly 
met  with.  The  electric  reaction  is  perfectly  normal. 
Recovery  may  be  expected  within  two  or  three  weeks. 

2.  The  middle  form.  The  electric  reaction  is  dimin- 
ished, but  not  lost.  At  the  expiration  of  about  three 
weeks  there  is  an  increase  of  the  galvanic  excitability  of 
the  muscles.  The  anodal  closure  contraction  (A  C  C)  is 
greater  than  the  kathodal  closure  contraction  (K  C  C). 
Recovery  usually  ensues  at  the  end  of  six  weeks. 

3.  In  the  severe  form,  there  is  loss  of  the  faradic  and 
galvanic  excitability  of  the  nerve  and  loss  of  faradic 
excitability  of  the  muscles.     The  reaction  of  degeneration 


PERIPHERAL  PARALYSIS.  101 

is  complete,  and  the  prognosis  is  unfavorable.  Recovery, 
in  cases  which  are  at  all  cured,  is  very  tedious.  At  a 
late  stage  there  is  often  spasmodic  contraction  of  the 
muscles  inserted  at  the  mouth  when  the  patient  smiles 
or  laughs,  or  is  engaged  in  animated  conversation. 

Course  and  Prognosis.  In  the  rheumatic  variety  of  facial 
paralysis  much  depends,  as  already  mentioned,  on  the 
result  of  the  electrical  examination  in  regard  to  prog- 
nosis. If  the  electric  excitability  remains  normal  at  the 
end  of  three  weeks,  recovery  w^ll  speedily  be  established. 
Manifest  reaction  of  degeneration  offers  little  hope  of 
curability.  The  paralysis  from  ear  trouble  disappears 
with  the  latter.  In  basal  tumor,  if  not  due  to  syphilis,  it 
is  absolutely  incurable.  The  facial  paralysis  in  infants 
after  forceps  delivery  passes  off'  quickly. 

Diagnosis.  Slight  cases  of  facial  paralysis  are  only 
recognizable  during  the  acts  of  laughing  and  crying.  The 
distortion  of  the  mouth  simulates  spasm  of  the  healthy 
side.  In  general,  the  symptoms  of  facial  paralysis  are 
so  manifest  that  mistakes  can  hardly  happen.  Of  greater 
importance  is  the  discrimination  between  peripheral 
and  central  facial  paralysis.  The  differential  diagnosis 
must  consider  the  etiology  and  concomitant  symptoms 
of  the  individual  case.  External  injury,  compression, 
exposure  or  aural  disturbance  indicate  the  existence  of 
peripheral  paralysis.  Imperfect  closure  of  one  eye  points 
the  same  way.  In  the  paralysis  of  cerebral  origin  there 
is  seldom  immobility  of  the  muscles  in  the  region  of  the 
forehead  and  the  eye.  Complication  with  paralj^sis  of 
other  cranial  nerves,  or  especially  the  co-existence  of 
hemiplegia,  signifies  a  central  lesion.  The  electric  excit- 
ability is  not  usually  abnormal  in  the  latter  form  of 
paralysis. 


10?  MA  X  UA  L   0  F  NERVO  US   D  I  SEAS  ES. 

Treatment.  The  indications  of  causal  treatment  in  rela- 
tion to  affections  of  the  parotid  gland,  otitis  or  syph- 
ilis require  the  first  attention.  In  all  other  cases  there  is 
no  remedy  equal  in  efficacy  to  electricity,  though  uni- 
form or  brilliant  results  must  not  be  too  confidently 
expected.  In  paralysis  of  recent  date,  it  is  recommended 
to  apply  a  weak,  stabile  galvanic  current  to  the  auriculo- 
mastoid  fossa  for  two  or  three  minutes  every  other  day. 
But  the  chief  method  at  a  later  period  is  to  place  the 
anode  in  the  same  fossa,  and  gently  stroke  the  paralyzed 
nerves  and  muscles  with  the  kathode.  Faradization  of 
the  muscles  may  also  be  of  service  in  tedious  cases. 
Injections  of  strychnia  are  disappointing. 

Paralysis  of  the  Sterno-Cleido  Mastoid. 
The  head  is  inclined  to  the  healthy  side,  and  the  chin 
is  raised  and  directed  towards  the  opposite  side.  Motion 
in  the  opposite  direction  is  difficult.  The  deformity  is 
temporarily  rectified  by  passive  movement  of  the  head. 
This  cannot  be  accomplished  in  spasmodic  contraction  of 
the  muscle. 

Paralysis  of  the  Trapezius. 

The  shoulder  sinks  downwards  and  forwards,  and  the 
act  of  "  shrugging  the  shoulder"  is  impaired.  Raising 
the  arm  above  the  horizontal  position  is  difficult.  The 
normal  condition  of  the  scapula  in  relation  to  the  verte- 
bral column  is  altered. 

Simultaneous  paralysis  of  the  sterno-cleido  mastoid  and 
the  trapezius  is  often  seen,  as  both  muscles  are  supplied 
by  external  branches  of  the  spinal  accessory  nerve. 


PERIPHERAL   PARALYSIS.  WS 

Paralysis  of  the  Pectoralis — Major  and  Minor. 

Isolated  paralysis  of  these  muscles  is  extremely  rare. 
The  anterior  thoracic  nerve  is  distributed  to  these  muscles. 
Abduction  of  the  upper  arm  is  impossible,  and  the  hand 
cannot  be  placed  on  the  shoulder  of  the  opposite  side. 

Paraiasis    of  the  Rhomboidii  and    Levator  Angul.^ 
Scapula. 
The  shoulder-blade  cannot  be  approximated  to  the  ver- 
tebral column,  nor  elevated.     This  form  of  paralysis  can 
only  be  recognized  when  the  trapezius  is  also  effected. 

Paralysis  of  the  Latissimus  Dorst  {subscapular  nerve) 
usually  results  from  lifting  heavy  weights.  The  hand 
cannot  be  placed  on  the  sacrum.  There  is  no  deformity 
observed  when  the  body  is  at  rest. 

Paralysis  of  the  Outward  and  Inward  Rotators  of 
THE  Humerus. 
Movements  with  the  teres-major  and  sub-scapular 
muscles  on  the  opposite  side  of  the  body  are  impaired. 
Rotation  of  the  arm  outward  is  abolished  when  the  teres- 
minor  and  scapularis  are  paralyzed.  This  form  of  paral- 
ysis causes  marked  interference  with  the  acts  of  writing 
and  sewing. 

Paralysis  of  the  Serratus  Magnus. 

(Thoracic  Longus  Nerve.) 

It  is  observed,  when  the  body  is  at  rest,  that  the  lower 

angle  of  the  shoulder-blade  is  somewhat  approximated  to 

the  vertebral  column   and   slightly  inclined  upward  and 

outward.     The   patient   cannot  raise  the  arm  above  the 


104  MANUAL   OF  NERVOUS  DISEA  S  ES . 

horizontal  line,  and  the  indentations  of  the  muscle  on  the 
side  of  the  chest  do  not  become  conspicuous.  If  the 
scapula  is  pushed  forward,  the  patient  is  enabled  to  raise 
the  arm,  and  if  the  arm  is  extended,  the  very  character- 
istic symptom  of  paralysis  of  the  serratus  becomes 
apparent.  We  now  observe  the  wing-like  projection  of 
the  inner  border  of  the  scapula,  so  that  a  deep  fossa  is 
formed,  in  which  the  hand  can  readily  touch  the  inner 
surface  of  the  scapula. 

Paralysis  of  the  Deltoid. 

( Ci  re  u  771  flex  Ne  rve . ) 

The  arm  cannot  be  raised  to  the  head,  and  the  shoulder 

appears  sunken.     This  form   of  paralysis  can  be  easily 

distinguished  from  anchylosis  of  the  shoulder  by  passive 

movement,  which  is  impossible  in  the  latter  afifection. 

Paralysis  of  the  Biceps  and  Brachialis  Anticus. 
{Musculo-cutanens  Nerve ) 
is  rarely  isolated.     It  interferes  with  tlexion  of  the  fore- 
arm  when  in  supination.     In   pronation,  the  flexion  is 
assisted  by  the  action  of  the  supinator  longus. 

Paralysis  of  the  Muscles  Innervated  by  the  Mus- 
culo-spiral  Nerve. 
Peripheral  paralysis  in  the  distribution  of  this  nerve  is 
of  frequent  occurrence  from  injury  and  exposure.  This 
nerve  is  especially  prone  to  be  affected  in  chronic  lead 
poisoning;  in  pressure  from  badly-fitting  crutches  and 
tight  bandaging  of  the  arm,  and  also  from  compression  of 
the  nerve,  where  it  curves  around  the  humerus.  The 
latter  causes  produce  a  nnld  form  of  paralysis. 


PERIPHERAL   PARALYSIS.  105 

Paralysis  of  the  Triceps  is  unusual.  It  is  recognized 
by  inability  to  extend  the  arm;  but  in  the  experiment 
the  arm  must  be  raised  so  as  to  exclude  the  weight  of 
the  forearm. 

Paralysis  of  the  Extensors  of  the  Forearm  causes  the 
''wrist  drop."  The  hand  hangs  down  in  the  flexed 
position  and  has  lost  its  "grasp."  Dorsal  flexion  of  the 
hand  is  impossible.  Its  lateral  movements  are  difficult. 
The  fingers  cannot  be  extended  nor  spread  apart,  but 
the  extension  of  the  terminal  phalanges  is  found  to  be 
normal  if  the  first  phalanges  are  supported.  Extension 
and  abduction  of  the  thumb 'is  abolished.  The  flexed 
forearm  can  be  supinated  by  the  biceps,  but  if  the  forearm 
be  extended  and  pronated  it  cannot  be  supinated.  The 
characteristic  prominence  of  the  supinator  lons^us  is  want- 
ing if  the  forearm  is  forcibly  extended,  whilst  the  patient 
tries  to  resist  the  attempt  by  fixing  the  semi-flexed  fore- 
arm in  the  pronated  position. 

The  electric  excitability  of  the  paralyzed  muscle  is 
normal  in  the  early  stage  and  continues  so  in  mild  cases. 
The  reaction  of  degeneration  becomes  manifest  on  the 
occurrence  of  atrophy.  Impairment  of  the  cutaneous 
sensibility  is  insignificant,  but  a  feeling  of  numbness  or 
creeping  often  ushers  in  the  paralysis. 

Ulnar  Paralysis. 
Isolated  ulnar  paralysis  is  relatively  of  unfrequent 
occurrence.  It  is  chiefly  caused  by  injury  of  the  elbow, 
the  wrist  or  the  ball  of  the  little  finger.  Implication 
of  the  flexor  carpi-ulnaris  interferes  with  complete  flex- 
ion and  lateral  movement  of  the  hand  towards  the  ulnar 
side.      Flexion   of  the   last   three   fingers   is   imperfect. 


106  MANUAL  OF  NERVOUS  DISEASES, 

The  movement  of  the  little  finger  is  totally  abolished. 
Paralysis  of  the  lumbricalis  prevents  the  spreading  of  the 
fingers.  Flexion  of  the  primary  phalanges  as  well  as 
extension  of  the  terminal  phalanges,  is  impossible,  in 
consequence  of  paralysis  of  the  interossii.  A  very  char- 
acteristic deformity  of  the  hand  develops,  which  is  ren- 
dered more  unsightly  by  the  grooves  of  the  atrophied 
interossii  on  the  back  of  the  hand.  This  peculiar  position 
of  the  hand  gives  the  appearance  of  the  ''  claw-like  hand  " 
(main  en  grifFe). 

Combined  Paralysis  of  Muscles  of  the  arm. 
Inj  uries  affecting  the  distribution  of  the  different  nerves 
proceeding  from  the  brachial  plexus  may  give  rise  to 
various  combinations  of  paralysis  of  the  upper  extremity 
Total  paralysis  of  the  plexus  is  caused  by  severe  contusion 
in  the  regions  of  the  neck  and  shoulder.  A  form  of  com- 
bined paralysis  is  described  by  Erb  involving  the  deltoid, 
the  biceps,  the  brachialis  anticus  and  the  supinator 
longus.  Duchenne  reports  similar  cases  of  paralysis  in 
new  born  infants,  caused  by  shoulder  delivery.  The  arm 
in  such  cases  hangs  down  by  the  side;  the  forearm  cannot 
be  flexed,  but  the  hand  and  fingers  are  not  affected. 

Treatment  of  Paralysis  of  the  Upper  Extremity.  It  is  only  in  rare 

instances  that  a  causal  treatment  is  possible.  The  chances 
of  cure  in  traumatic  cases  are  not  favorable.  Those  of  a 
rheumatic  origin  are  more  amenable  to  treatment.  The 
mildness  or  severity  of  the  paralysis  is  best  judged  by 
the  condition  of  the  electric  excitability.  The  greatest 
reliance  in  improving  the  muscular  power  must  be  placed 
in  electric  treatment,  and  the  more  recent  the  case  the 
better  is  the  prospect  of  cure.     A  good  method  is   to  gal- 


PERIPHERAL   PARALYSIS.  107 

vanize  Erb's  motor  point.  Each  muscle  should  also 
be  stimulated  by  stroking  or  dabbing  it  with  the  kath- 
ode. If  the  test  for  the  reaction  of  degeneration  gives 
early  anodal  closure  contractions,  it  is  preferable  to  excite 
the  muscle  with  the  anode,  while  the  kathode  is  placed 
on  a  distant  part.  Faradization  proves  useful  in  exciting 
reflex  action.  In  all  cases  patience  and  perseverance  in 
continuing  the  electric  treatment  is  necessary  if  any 
benefit  is  to  be  achieved.  The  more  obstinate  the  case 
the  more  persistent  should  be  the  treatment.  Massage  and 
the  use  of  liniments  should  not  be  neglected. 

Peripheral  Paralysis  of  Muscles  of  the  Inferior 
Extremity. 

This  form  of  paral3^sis  occurs  in  injury  of  the  thigh, 
disease  of  the  vertebrae,  compression  from  pelvic  tumor  and 
in  psoas  abscess.  It  is  also  to  be  observed  that  defective 
innervation  of  muscles  inserted  in  the  vertebral  column 
interferes  with  walking,  in  consequence  of  the  insecure 
equilibrium  of  the  body. 

Paralysis  of  the  crural  nerve.  The  symptoms  in  this 
form  of  paralysis  are  due  to  the  implication  of  the  illio- 
psoas  and  the  quadriceps  extensor  muscles.  The  thigh 
cannot  be  flexed  on  the  pelvis,  and  the  trunk  cannot  be 
raised  from  the  recumbent  position.  Anaesthesia  is  some- 
times observed  in  the  lower  half  of  the  anterior  aspect 
of  the  thigh  and  along  the  course  of  the  saphenus  nerve. 

The  characteristic  symptoms  of  paralysis  of  the  obtu- 
rator nerve  is  defective  abduction  of  the  thigh.  The 
patient  is  therefore  unable  to  cross  one  leg  over  the  other. 

Paralysis  of  the  gluteal  nerves  causes  impaired  abduction 
of  the  thigh  and   difficulty  of  rotating  it  inwards.     The 


108  MANUAL   OF  NERVOUS  DISEASES. 

trunk  sways  from  side  to  side  in  mounting  and  descend- 
ing steps. 

Paralysis  in  the  region  of  the  thigh  results  from  injury 
and  disease  of  the  vertebrae,  pelvic  tumor,  hard  labor 
and  rheumatic  influences.  Isolated  paralysis  of  the  differ- 
ent branches  of  the  sciatic  nerve  may  occur  from  any  of 
these  causes.     Paralysis  of  the  foot  is  the  most  common. 

In  paralysis  of  the  i^eroneal  nerve  there  is  inability  of 
voluntary  dorsal  flexion  of  the  foot.  The  tips  of  the  toes 
and  the  outer  edge  of  the  foot  first  touch  the  ground  in 
walking,  as  the  abduction  of  these  parts  is  abolished. 
A  similar  condition  is  characteristic  of  infantile  spinal 
paralysis. 

Paralysis  of  the  tibial  nerve  completely  abolishes  plantar 
flexion.  It  is  impossible  for  the  patient  to  rise  on  his 
toes.  Secondary  contraction  of  the  calf  muscles  grad- 
ually develops  talipes  calcaneus.  A  claw-like  appearance 
of  the  foot  is  caused  by  atrophy  of  the  interossii. 

Paralysis  of  the  trunk  of  the  sciatic  nerve  causes,  in  addi- 
tion, paralysis  and  atrophy  of  the  foot,  and  inability  to  flex 
the  leg  backward  on  the  thigh.  This  is  due  to  the  impli- 
cation of  the  biceps,  semi-membranous  and  semi-tendinous 
muscles.  Walking  is  still  possible  if  only  one  extremity 
is  afl'ected,  as  the  quadriceps,  which  usually  escapes, 
stiffens  the  limb. 

Vaso-m'otor  and  trophic  symptonis  are  quite  frequent,  as 
shown  by  the  cyanosis^  coldness  of  the  skin  and  atrophy 
of  the  muscles. 

Impairment  of  the  electric  excitability  is  manifest,  as  in 
all  cases  of  peripheral  paralysis. 

Treatment  accords   with   the    same    principjes    observed 


PERIPHERAL   PARALYSIS.  109 

in  the  management  of  peripheral  paralysis  of  the  upper 
extremity. 

Lead  Paralysis. 

Chronic  lead  poisoning  occurs  among  type-setters,  type- 
founders, house  painters,  potters,  workers  in  white-lead 
factories,  and  among  all  artisans  who  expose  themselves 
to  the  introduction  of  small  quantities  of  the  metal  or  its 
salts.  The  paralysis  usually  makes  it  appearance  subse- 
quent to  attacks  of  colic. 

As  lead  palsy  belongs  to  the  class  of  atrophic  paralysis, 
it  may  be  inferred  that  the  toxic  action  of  the  metal 
either  produces  degenerative  changes  in  the  gray  sub- 
stance of  the  cord  or  analogous  changes  in  peripheral 
motor  fibres.  Certainty  in  regard  to  this  pathological 
question  has  not  yet  been  obtained,  but  recent  investiga- 
tions tend  to  show  that  the  anatomical  change  of  nerve 
fibres  is  the  primary  condition. 

Clinical  History.  Lead  paralysis  is  a  bilateral  affection. 
In  the  large  majority  of  cases  the  paralysis  is  lim- 
ited to  the  extensor  muscles  of  the  forearm,  but  the 
triceps  and  the  supinator  longus  remain  remarkably 
exempt.  The  conspicuous  symptom  is  the  "wrist  drop." 
Occasionally  the  muscles  of  the  upper  arm  are  also 
implicated.  Lead  palsy  of  the  lower  extremities  is  rarely 
seen.  Atrophy  of  the  affected  muscles  develops  in  all 
severe  cases,  and  the  reaction  of  degeneration  is  observed. 
Tremor  of  the  paralyzed  part  is  sometimes  seen  in  aggra- 
vated cases,  and  attended  by  anaesthesia. 

Treatment.  Recent  cases  of  lead  paralysis  are  often 
promptly  cured  by  the  frequent  use  of  warm  sulphur 
baths  and  the  employment  of  electricity  as  indicated  in 


no  MANUAL  OF  NERVOUS   DISEASES. 

all  forms  of  peripheral  paralysis.  Iodide  of  potassium  is 
believed  to  promote  the  elimination  of  the  lead  poison 
from  the  system.  Very  aggravated  cases,  that  manifest 
the  reaction  of  degeneration  and  show  much  muscular 
atrophy,  do  not  permit  of  a  favorable  prognosis. 

Arsenical  Paralysis. 
This  form  of  paralysis  is  less  frequently  met  with  than 
lead  palsy.  It  succeeds  the  symptoms  of  acute  arsenical 
poisoning.  The  paralysis  affects,  in  the  larger  number 
of  cases,  the  inferior  extremities.  Severe  pain  is  felt  in 
the  limbs  and  sacrum,  attended  by  anaesthesia.  These 
S3'mptoms  are  characteristic  of  arsenical  paralysis. 
Atrophy  of  the  paralyzed  muscles  finally  ensues.  It  is 
undetermined  whether  the  anatomical  change  underlying 
the  paralysis  is  a  neuritis  or  myelitis.  Recovery  is  some- 
times  rapid  and  is  hastened  by  electricity. 

Diphtheric  Paralysis. 
The  paralysis  of  diphtheria  usually  develops  in  the 
course  of  the  third  or  fourth  week  after  the  termination 
of  the  primary  disease.  Paralysis  of  the  soft  palate  is 
the  first  symptom  that  attracts  attention.  This  is  indi- 
cated by  the  nasal  twang  of  the  voice  and  difhculty  of 
deglutition.  The  ocular  muscles  are  sometimes  impli- 
cated, causing  ptosis,  strabismus  or  mydriasis.  A  paretic 
condition  of  the  lower  extremities  is  occasionally  observed. 
Sensory  disturbances  always  accompany  the  paralysis, 
especially  obtuseness  of  the  mucous  membrane  of  the 
lips,  tongue  and  cheeks.  But  the  most  serious  occurrences 
in  diphtheric  paralysis  relate  to  irregularity  of  the  heart's 
action  and  embarrassment  of  the  respiration.  Sudden 
death  may  happen  from  fatal  syncope  and  asphyxia. 


PERIPHERAL    PARALYSIS.  Ill 

Disappearance  of  the  paralysis  usually  takes  place  in 
the  course  of  a  few  weeks  if  it  is  limited  to  the  palate; 
even  severe  and  protracted  cases  tend  to  recovery.  The 
general  treatment  tends  to  improve  the  patient's  strength, 
fur  which  quinia,  iron  and  cod  liver  oil  constitute  the 
approved  remedies.  Electric  treatment  is  of  much  benefit 
in  acting  favorably  on  the  paralyzed  muscles. 

Reflex  Paralysis. 
By  this  term  is  meant  a  paralytic  affection  dependent 
on  an  irritation  existing  in  a  remote  organ.  The  most 
common  example  of  such  a  form  of  paralysis  is  the  occur- 
rence of  paraplegia  in  urinary  disease.  Intestinal  and 
uterine  troubles  may  also  give  rise  to  this  type  of  paraly- 
sis. Leyden  attributes  the  paralysis  in  such  cases  to  an 
ascending  or  migrating  neuritis  which  starts  from  the 
diseased  part  and  secondarily  affects  the  spinal  cord. 
Treatment  must  be  directed  to  the  cure  of  the  primary 
cause,  but  the  paralysis  may  persist  and  require  special 
treatment. 


CHAPTER   VI. 
VARIETIES  OF  LOCAL  SPASM. 

Spasm  of  the  Muscles  of  the  Eyeball. 

Tonic  spasm  of  the  internal  rectus,  which  is  the  most 
frequent  of  the  local  spasms  of  the  ocular  muscles,  is 
recognized  by  the  presence  of  strabismus.  It  is  often 
caused  by  long  standing  paralysis  of  the  external  rectus. 

Nystagmus  is  a  bilateral  affection.  It  consists  of  clonic 
spasm  of  the  muscles  of  the  eyeballs,  and  is  especially 
noticeable  when  the  patient  looks  at  remote  objects. 
The  eyes  are  affected  with  oscillatory  movements. 
Nystagmus  is  associated  with  various  local  affections  of 
the  eyes.  It  is  also  often  seen  in  acute  meningitis,  and  is 
a  frequent  symptom  in  multiple  sclerosis  of  the  brain. 

Spasm  of  the  Masticatory  Muscles. 

Trismus  is  a  tonic  spasm  of  the  muscles  of  mastication. 
It  is  rarely  seen  as  an  isolated  affection,  but  constitutes 
a  prominent  symptom  of  tetanus,  and  occurs  in  hysteria. 
The  closure  of  the  jaws  is  caused  by  the  firm  contraction 
of  the  masseter  muscles  (lockjaw). 

In  the  clonic  spasm  of  the  masticatory  muscles  the 
lower  jaw  is  constantly  moved  in  the  vertical  direction, 
and  gives  rise  to  chattering  of  the  teeth. 

(112) 


LOCAL  SPASM.  113 

Both  varieties  of  local  spasm  probably  depend  on  reflex 
action,  which  may  be  excited  either  by  an  irritation  in 
the  jaw  itself,  such  as  decayed  teeth,  or  by  an  affection 
in  a  remote  organ. 

Treatment  aims  at  the  removal  of  the  discoverable 
cause.  Difficulty  of  feeding  must  be  overcome  by  intro- 
ducing food  through  the  nose  by  means  of  a  small 
oesophageal  tube.  Galvanization  is  sometimes  very  ser- 
viceable. Hypodermic  injections  of  morphia  or  atropia 
and  the  internal  use  of  the  bromides,  arsenic  and  zinc 
may  be  tried  in  succession  in  obstinate  cases. 

Facial  Spasm  (Convulsive  Tic). 

In  the  absence  of  any  recognizable  cause  of  this  practi- 
cally most  important  form  of  local  spasm,  we  can  only 
conjecture  the  existence  of  a  hereditary  or  neuropathic 
tendency  that  predisposes  to  its  development.  Convuls- 
ive tic  is  sometimes  caused  by  direct  reflex  action,  as  in 
neur£ilgia  of  the  fifth  nerve,  or  indirectly  under  the  influ- 
ence of  a  source  of  irritation  in  a  remote  organ,  as  in 
uterine  disease.  Facial  spasm  has  also  been  known  to 
occur  immediately  after  violent  emotional  disturbance. 
Perhaps  in  many  cases  the  source  of  irritation  is  central. 
The  acquired  habit  of  grimaces,  observed  in  children 
through  imitation,  is  a  tonic  spasm  of  facial  muscles. 

Clonic  spasm  of  the  face  is^ usually  a  bilateral  disease. 
It  occurs  periodically,  and  may  be  excited  by  the  acts  of 
mastication,  talking  or  a  mental  impression.  The  move- 
ments produce  contortion  of  the  features.  The  contrac- 
tion in  severe  cases  may  also  involve  the  tongue  and  the 
muscles  of  the  neck.  There  are  patients  who  constantly 
make  the  strangest  grimaces,  while  in  others  they  recur 


lU  MANUAL   OF  NERVOUS  DISEASES. 

at  irregular  periods.  The  affected  muscles  carry  out 
normal  movements  during  the  intervals  and  are  free 
from  pain  or  other  sensory  disorders.  The  so-called 
*' tricks"  are  of  the  nature  of  clonic  spasm. 

Partial  spasm  of  the  eyelids  either  causes  constant 
winking  (nictitating  spasm);  or  the  entire  orbicularis  pal- 
bebrarum  may  be  affected  with  tonic  and  clonic  spasm. 
The  contractions  cause  firm  closure  of  the  eyes,  that  may 
last  for  minutes  or  hours  (blepharospasm).  The  spas- 
modic paroxysms  are  as  a  rule  bilateral.  Very  often  the 
spasm  is  excited  by  affections  of  the  eyes,  or  tic  doloreux, 
but  often  no  cause  is  discoverable.  The  involuntary  grin 
(risus  sardonicus)  is  due  to  convulsive  movements  of 
the  muscles  supplied  by  the  malar  and  labial  twigs 
of  the  facial  nerve. 

Facial  spasm  is  not  easily  remedied  by  treatment,  unless 
the  exciting  cause  of  the  reflex  movements  be  removed. 
Resection  of  the  supraorbital  nerve  is  recommended  if 
obstinate  neuralgia  of  this  nerve  is  at  the  bottom  of  the 
spasm.  Favorable  results  from  this  operation  are 
reported.  Improvement  of  the  sj^asm  has  been  observed 
from  the  application  of  Paquelin's  thermo-cautery  to  the 
cervical  vertebrae.  Electricity  deserves  a  fair  trial  before 
resorting  to  severe  measures.  The  anode  of  a  stabile 
constant  current  is  to  be  applied  to  the  affected  muscles 
and  brought  in  contact  with  the  tender  points  of  the 
nerve,  which  should  be  searched  for.  In  using  the  inter- 
rupted current  it  is  recommended  to  begin  TAith  a  weak 
strength  and  gradually  to  increase  it.  Some  benefit  is 
also  claimed  from  the  use  of  the  bromide  of  potassium  in 
large  doses. 


LOCA  L   SPASM.  115 

Lingual  Spasm. 
This  is  rarely  an  independent  affection.  The  tongue 
is  commonly  affected  in  epileptic  and  hystericfil  spasms. 
When  occurring  as  an  isolated  condition  it  interferes  with 
speech  and  respiration.  The  tongue  during  the  spasm  is 
thrown  backwards  and  up  against  the  hard  palate. 
Relief  is  afforded  by  pulling  the  tongue  forward  with  a 
forceps.  To  allay  the  spasm  it  may  become  necessary  to 
use  chloroform. 

Spasm  of  the  CEsophagus. 
Spasmodic  stricture  of  the  oesophagus  is  usually  met 
with  in  hysterical  women,  and  is^  often  so  persistent  as  to 
simulate  organic  disease.  The  so-called  "  globus  hj^steri- 
cus"  is  supposed  to  be  a  spasmodic  affection  of  this  kind. 
The  oesophageal  tube  can  be  passed  with  little  difficulty 
in  the  hysterical  disorder.  An  anaesthetic  may  be 
required  to  overcome  the  obstinacy  of  the  spasm. 

Spasm  of  the  Respiratory  Muscles. 

Spasmodic  attacks  of  the  glottis  occurring  in  children 
is  usually  described  under  the  name  of  laryngismus  stri- 
dulus, or  "  false  croup."  This  affection  often  coexists 
with  infantile  convulsions.  The  exciting  cause  in  many 
cases  is  difficult  dentition  or  derangement  of  the  digestive 
organs.  Ricketty  and  weakly  children  are  especially 
prone  to  attacks. 

The  paroxysm  comes  on  suddenly  without  any  warn- 
ing. It  consists  of  complete  closure  of  the  glottis.  Res- 
piration is  arrested  and  suffocation  appears  imminent. 
At  the  same  time  the  fingers  are  pressed  against  the  palm 
of  the   hand    and    the  lower   extremities    are   extended. 


116  MANUAL  OF  NERVOUS  DISEASES. 

Towards  the  termination  of  the  spasm,  which  lasts  but  a 
few  seconds,  respiration  is  gradually  reestablished,  and 
relief  of  the  glottis  is  announced  by  a  sonorous,  crowing 
inspiration,  provided  there  is  no  occurrence  of  general  con- 
vulsions. Death  from  asphyxia  during  one  of  the  attacks 
often  happens. 

It  is  seldom  that  the  physician  arrives  in  time  to  wit- 
ness the  spasm.  He  usually  finds  the  little  patient  in  a 
warm  mustard  bath,  which  is  probably  as  good  as  any- 
thing that  can  be  done  for  the  moment. 

Complicated  Spasms  of  the  Respiratory  Muscles 
are  seen  only  in  hysteria.     They  consist  of  fits  of  laugh- 
ing and  crying,  a  brassy  cough,  gurgling  and  squeaking 
sounds,  snuffling,   fluttering  at   the  heart    and    extreme 
rapidity  of  the  respiration. 

Spasm  of  the  Diaphragm  [Singultus). 
Ordinary  hiccough  is  a  sudden  contraction  of  the  dia- 
phragm. Persistent  hiccough  is  often  a  hysterical  symp- 
tom. It  is  sometimes  exceedingly  troublesome  and  even 
exhausting.  The  worst  case  of  hiccough  I  have  ever  seen 
occurred  in  a  young  healthy  man,  who  had  been  two  days 
under  treatment  without  receiving  relief.  It  happened 
to  him  after  having  taken  a  hasty  lunch  at  a  railroad 
station.  I  found  him  sitting  in  an  arm-chair  in  a  reclin- 
ing position,  and  with  both  hands  firmh^  grasping  a  stick 
to  support  himself.  The  hiccough  was  incessant  and 
violent.  The  spasm  was  promptly  checked  by  several 
ten-grain  doses  of  musk.  Hiccough  is  an  ominous  symp- 
tom in  severe  affections  of  the  bowels,  and  in  peritonitis. 
Persistent  hiccough   isusually  arrested   by  morphia  or  a 


LOG  A  L   SPASM.  117 

few  whiffs  of  chloroform.  Galvanism  is  also  useful. 
One  pole  is  to  be  applied  to  the  side  of  the  neck  and 
the  other  to  the  epigastrium. 

Spasm  of  the  Muscles  of  the  Neck. 

The  mild  form  of  "  wry  neck"  is  usually  of  rheumatic 
origin.  The  spasm  is  a  tonic  unilateral  contraction  of 
the  sterno-cleido  mastoid.  The  more  severe  variety  of 
"torticollis  spastica"  is  seen  in  disease  of  the  cervical 
vertebra.  Frequently  several  of  the  muscles  of  the  neck 
are  simultaneous!}^  aflfected. 

In  unilateral  spasm  of  the  storno-cleido  mastoid,  the 
head  is  turned  to  the  opposite  side  and  the  chin  is  raised. 
If  the  trapezius  is  similarly  affected  the  head  is  turned 
backward  towards  the  shoulder  of  the  same  side. 

In  spasm  of  the  sjjleniiis,  whether  isolated  or  combined 
with  spasm  of  other  muscles  of  the  neck,  a  firm  ridge  is 
seen  beneath  the  outer  portion  of  the  trapezius. 

Bilateral  Clonic  Spasm, 
in    which  the    deep    muscles    of  the    neck    are  affected, 
usually  occurs  in  children.    It  causes  nodding  or  rotatory 
movements    of    the    head,    which    may    attain    to    great 
severity. 

General  Treatment.  All  cases  of  chronic  spasm  of  the  mus- 
cles of  the  neck  offer  great  difficulty  to  treatment.  The 
greatest  amount  of  relief  is  obtained  from  mechanical 
apparatus  that  supports  the  head,  as  the  spasm  usually 
ceases  when  the  head  is  at  rest.  Electric  treatment  is 
occasionally  of  benefit  Either  current  may  prove  useful 
by  methods  which  experience  in  the  special  case  may 
indicate.     A  resort    to  the  red-hot    iron    to   the   back    is 


118  MA  NUA  L  O  F  NER  VO  US  DISEA  SES. 

recommended  by  some  observers.  Internal  remedies 
appear  to  be  of  little  use.  ^lorphia  injections  may 
become  indispensable  to  afford  the  patient  some  respite 
from  the  painful  or  constant  spasmodic  contractions. 

Spasm  of  the  Muscles  of  the  Upper  Extremity. 

Convulsive  movements  of  the  muscles  of  the  upper 
extremity  are  usually  seen  in  central  disease  and  in 
hysteria.  The  tonic  spasm  of  the  arm  in  brachial  neu- 
ralgia is  a  reflex  action. 

Tonic  spasm  of  the  rhomhoidii  causes  a  peculiar  position 
of  the  scapula.  Its  inner  border  runs  obliquely  upward 
and  outward,  and  its  lower  border  approximates  the  ver- 
tebral column.  The  arm  cannot  be  raised  in  the  upright 
direction,  which  also  is  seen  in  paralysis  of  the  serratus; 
but  in  the  latter  affection  the  scapula  stands  off  from  the 
spine. 

Tonic  spasm  of  the  pectoralis  wajor,  the  deltoid  and  the 
latissimus  dorsi  and  analogous  isolated  contractions  of 
muscles  of  the  back  and  shoulder  are  of  rare  occurrence. 
Their  existence  is  recognized  by  the  hindrance  they  offer 
to  normal  movement  of  the  parts  and  the  rigid  condition 
of  the  affected  muscles. 

The  Flexors  of  the  Hand  and  Fingers 
are  frequently  subject  to  tonic  spasm.  The  hand  is 
flexed  towards  the  radial  side  and  is  rendered  concave- 
In  tonic  spasm  of  the  muscles  of  the  fingers  supplied  by 
the  ulnar  nerve,  the  thumb  is  adducted  and  the  little 
finger  is  strongly  flexed. 

Treatment.  All  these  isolated  forms  of  spasm  are  best 
treated  with  the  constant  current.     The  rule  is  to  apply 


LOCAL  SPASM.  119 

the  anode  of  a  stabile  current  to  the   spasmodic  muscles 
and  the  kathode  to  an  indifferent  point. 

Saltatory  Spasm. 
This  is  a  peculiar  form  of  reflex  spasm  affecting  the 
lower  extremities,  but  only  when  the  patient  attempts  to 
stand  or  walk.  The  moment  the  soles  touch  the  floor 
very  energetic  contractions  begin  in  the  muscles  of  the 
leg,  which  forces  the  patient  to  jump  or  to  hop.  This 
affection  is  occasionally  seen  in  nervous  and  hysterical 
individuals. 

WRITERS'  CRAMP  AND  ALLIED   PROFESSIONAL 
NEUROSES. 

Among  the  disorders  of  co-ordination  in  persons  follow- 
ing occupations  that  require  the  constant  use  of  the  hand 
and  fingers,  none  is  as  frequently  seen  as  "writers' 
cramp."  There  is  no  defect  of  the  gross  muscular  power 
of  the  hand,  but  as  soon  as  the  patient  begins  to  write,  he 
loses  the  control  of  the  associated  muscular  movements 
needed  in  using  the  pen.  The  right  hand  being  the  one 
usually  employed  is  oftenest  affected.  No  other  cause 
is  known  than  the  constant  use  of  the  pen. 

Symptoms.  The  trouble  generally  develops  gradually. 
At  the  beginning,  writing  is  rendered  difficult,  and  finally 
it  becomes  impossible.  There  are  various  ways  in  which 
the  movements  in  using  the  pen  are  disturbed.  A  fre- 
quent variety  of  the  affection  consists  of  a  spasmodic 
condition  of  the  fingers  as  soon  as  the  pen  is  seized.  The 
pen  is  so  firmly  pressed  by  the  fingers  that  it  cannot  follow 
the  impulse  of  the  writer.  In  another  form  the  arm  is 
quickly  tired  out  and  at  last  becomes  powerless  to  con- 


120  MANUAL  OF  NERVOUS  DISEASES. 

duct  the  pen,  or  the  limb  is  affected  with  a  tremor  so  that 
the  letters  are  distorted  and  the  writing  illegible.  Occa- 
sionally improvement  takes  place  after  the  patient  has 
desisted  for  some  time  from  using  the  pen,  but  in  general 
he  is  finally  compelled  to  relinquish  the  effort.  Persons 
affected  with  writers'  cramp  are  often  subject  to  other 
functional  disturbances  of  the  nervous  system. 

Treatment.  Cessation  of  writing  for  weeks  or  months  is 
absolutely  necessary  whatever  plan  of  treatment  be 
adopted.  It  is  of  no  avail  for  the  patient  to  learn  to  write 
with  the  other  hand,  for  that  will  very  soon  be  similarly 
affected  with  the  cramp.  Many  contrivances  have  been 
devised  for  facilitating  the  act  of  writing.  The  one  which 
appears  to  give  much  satisfaction  is  a  sort  of  bracelet  to 
which  a  penholder  is  attached,  that  supports  the  out- 
stretched fingers.  In  mild  cases  the  patient  may  succeed 
in  writing  if  he  rests  the  whole  arm  upon  a  low  desk. 

The  judicious  and  persevering  use  of  galvanism  has 
given  some  good  results.  One  of  the  methods  is  to 
apply  the  anode  of  a  weak  current  to  the  muscles  of  the 
arm  and  fingers,  and  the  kathode  to  the  region  of  the 
cervical  vertebra.  Interruptions  are  to  be  avoided.  The 
faradic  current  appears  to  do  more  harm  than  good. 

Brilliant  cures  have  lately  been  reported  from  systematic 
massage  treatment.  No  special  rules  can  be  laid  down 
for  the  varied  and  complicated  manipulations  which  are 
necessary  to  achieve  success.  To  acquire  the  proper  skill 
it  is  indespensable  to  be  familiar  with  the  nice  and  har- 
monious play  of  the  muscles  in  the  act  of  writing. 

Professional  neuroses  are  also  met  wdth  among  piano- 
forte players,  telegraph  operators,  type-writers,  cigarette- 
rollers,  tailors,  shoemakers  and  engravers. 


LOCAL  SPASM.  /f/ 

Milkmaids'  Cramp. 
In  most  cases  both  hands  are  affected  with  spasmodic 
contractions  on  attempting  any  kind  of  movement,  but 
particularly  that  of  prehension.  The  median  and  super- 
ficial radial  nerves  are  involved.  Treatment  is  the  same 
as  that  of  writers'  cramp. 


CHAPTER  VII. 
MINOR    NEUROSES 

Headache. 

The  clinical  importance  of  headache  is  to  be  rated  in 
accordance  with  its  persistence  and  association  with  other 
symptoms.  In  all  febrile  affections  and  grave  diseases 
of  the  brain,  headache  is  a  very  frequent  con- 
comitant. Severe  and  constant  pain  in  the  head  attends 
cerebral  meningitis,  brain  tumor  and  cerebral  syphilis. 
Migraine  and  neuralgia  of  the  trigeminus  and  disease 
of  the  upper  cervical  nerves  must  be  distinguished  from 
ordinary  headache.  Headache  is  also  a  common  reflex 
symptom  in  a  variety  of  morbid  conditions.  Gastric 
derangement  and  sluggish  bowels  are  often  accompanied 
by  frontal  headache.  A  distressing  form  of  headache 
occurs  in  cerebral  anaemia  and  neurasthenia.  Rheumatic 
headache  affects  the  scalp,  usually  the  occipital  region. 
Toxic  influences  such  as  alcoholism,  chronic  lead  and 
nicotine  poisoning,  frequently  give  rise  to  headache. 

Physical  overexertion  and  mental  excitement  consti- 
tute daily  causes  of  headache.  On  excluding  all  these 
manifold  sources  of  headache,  there  still  remains  a  pecu- 
liar form  of  the  malady  which  is  usually  called  "  nervous 
headache"  or  ''habitual  headache."  Its  paroxysmal 
occurrence  has    been   quaintly    termed   a  "nerve   storm." 

(122) 


MINOR  NEUROSES.  ITS 

There  are  people  who  are  never  without  headache.  Prob- 
ably in  numerous  cases  this  functional  affection  is  due  to 
a  constitutional  predisposition.  The  pathology  of  habitual 
headache  can  only  be  conjectured.  It  may  be  said  that 
the  brain  substance  is  in  an  irritable  condition.  We 
know,  however,  that  sensory  filaments  from  the  trigeminus 
are  sent  to  the  dura  mater.  Circulatory  disturbances  of  the 
brain  of  the  nature  of  congestion,  arising  under  well-known 
circumstances,  may  become  manifest  as  cephalalgia. 

Habitual  headache  greatly  varies  in  intensity  and  fre- 
quency of  occurrence  in  different  individuals.  Some 
patients  can  foretell  by  vague  sensations  that  an  attack 
is  coming  on.  An  attack  may  continue  for  half  an 
hour  or  last  a  day  or  two.  The  headache  may  only 
amount  to  a  dull,  heavy  feeling,  diffused  over  the  whole 
head,  or  the  pain  is  limited  to  a  particular  spot.  Patients 
often  give  graphic  descriptions  of  the  severity  of  the  pain. 
They  say,  it  feels  as  if  the  head  were  pressed  in  a  vice  ; 
or  if  it  were  crushed  or  split.  During,  and  even  some 
time  after  an  attack,  many  of  the  patients  manifest  much 
irritability  of  temper  ;  they  declare  themselves  unfit  for 
physical  or  mental  exertions. 

Habitual  headache  is  hard  to  cure.  There  may  be  a 
particular  exciting  cause  which  the  patient  can  perhaps 
avoid.  Overworked  and  debilitated  persons  should  seek 
rest  or  be  sent  to  the  country  or  the  seaside.  Tonics; 
especially  iron,  may  often  be  prescribed  with  advantage. 
The  coexistence  of  indigestion,  which  is  usually  accom- 
panied by  sluggish  bowels,  may  require  attention. 
Patients  often  ascribe  their  headache  to  a  particular  arti- 
cle of  diet,  or  think  they  suffer  from  dyspepsia,  and  then 
take  too  little   nourishment.     In   general  they  are  great 


m  M  A  NUA  L   O  F  NER  V  0  US   DfSEA  S ES . 

€onsuniers  of  cathartic  medicines.  This  is  all  wrong.  If 
a  mild  aperient  is  indicated  it  is  best  to  order  small  doses 
of  Carlsbad  salts  or  the  fluid  extract  of  cascara  sagrada. 

The  majority  of  patients  have  long  ago  come  to  the 
conclusion  that  nothing  will  help  their  headache,  and  are 
resigned  to  their  fate.  But  they  still  continue  to  resort 
lo  certain  remedies,  which  they  think  do  them  eome 
good,  or  which  really  give  them  some  relief.  Remedies 
Avhich  stand  in  much  repute  are  cold  applications  to  the 
head  ;  mustard  plasters  Vjchind  the  ears  or  on  the  tem- 
ples ;  a  hot  footbath,  strong  green  tea,  etc. 

There  is  no  lack  of  remedies  from  which  to  chooso. 
Quinia  takes  the  first  raidv,  and  next  comes  arsenic,  in 
the  form  of  Fowler's  solution.  Salicylate  of  soda  in  one 
large  dose  sometimes  averts  an  attack.  Guarano  in 
powder  form,  10  to  20  grains  every  two  hours,  is  occa- 
sionally of  service.  The  Eff.  bromo-caftein  is  a  very 
popular  remedy.  The  inonobromate  of  camphor  in  pills, 
from  4  to  6  grains,  is  also  much  prescribed.  Nervous 
persons  may  re<'eive  benefit  from  frequently  repeated 
mioses  of  aromatic  spirit  of  ammonia  or  sweet  spirits  of 
nitre.  Prompt  relief  is  often  obtained  from  phenacetin 
and  antipyrin.  Excellent  results  are  now  and  then 
observed  from  a  very  weak  constant  current.  For  a  min- 
ute or  two  the  electrodes  may  be  applied  to  the  temples, 
or  one  over  the  forehead  and  the  other  to  the  nape  of  the 
neck. 

HEMICRANIA. 

(Migraine.     Sick   Head  ache.) 
Etiology.      By  hemicrania  is  understood  a  peculiar  form 
of  headache,  affecting   only  one  side.     The  pain  is  gener- 
ally attended   by  vaso-motor  disturbar.ces.     ^^'omen   are 


MINOR  NEUROSES.  125 

chiefly  liable  to  this  affection.  Uusually  it  dates  from 
the  period  of  puberty,  but  genuine  migraine  also  occurs 
in  young  children.  The  cause  of  this  malady  is  obscure^ 
nor  is  it  known  with  certainty  Avhat  part  of  the  nervous 
system  is  primarily  involved.  Although  the  concomitant 
vaso-motor  symptoms  manifest  disturbance  of  the  cervical 
sympathetic,  they  may  nevertheless  be  of  a  reflex  char- 
acter, due  to  a  central  irritation.  Heredity  is  probably 
always  a  predisposing  cause.  Hemicrania  is  especially 
common  in  nervous  and  hysterical  women.  Mental 
excitement  is  very  liable  to  bring  on  an  attack. 

CliniCil  history.  Paroxysms  of  migraine  recur  at  irreg- 
ular periods,  though  in  some  women  they  coincide  with 
the  menstrual  flow.  A  majority  of  the  patients  enjoy 
their  usual  health  during  the  intervals,  while  others  still 
continue  to  be  troubled  with  various  nervous  complaints. 
The  onset  of  an  attack  is  often  announced  by  shuddering, 
sighing  and  yawning;  a  feeling  of  heaviness  and  of  pres- 
sure of  the  head;  flickering  before  the  eyes;  noises  in  the 
ear,  and  a  feeling  of  general  weakness.  The  attack 
begins  with  a  boring  or  thumping  pain,  first  in  the 
frontal,  then  in  the  temporal,  region,  and  finally  invades 
one-half  of  the  head,  in  the  majority  of  ca<^es  the  left 
side.  The  pain  has  not  the  intermittent  character  of 
neuralgia,  but  gradually  increases  in  intensity.  There 
are  no  painful  points  in  the  distribution  of  the  trigeminus, 
but  the  scalp  becomes  ver\^  sensitive  to  the  touch. 

At  the  height  of  the  attack  occur  the  disturbances  of 
the  special  senses  that  had  already  appeared  in  a  minor 
degree  during  the  prodromal  period.  The  ocular  symp- 
toms are  very  prominent,  consisting  of  shimmering  before 


126        MANUAL   OF  NERVOUS  DISEASES. 

the  eyes,  flashes  of  light  and  temporary  hemiopia  (hemi- 
crania  ophthahnica). 

The  vaso-motor  S3'mptoms  deserve  especial  notice,  as 
they  support  the  theory  of  migraine  being  an  affection  of 
the  sympathetic.  During  the  acme  of  the  attack,  in  a 
number  of  cases,  one-half  of  the  face  shows  decided 
pallor,  the  skin  is  cool,  the  temporal  arteries  are  con- 
tracted, the  pupils  are  dilated,  and  the  flow  of  saliva  is 
increased.  Towards  the  close  the  spastic  condition  of  the 
arteries  relaxes,  the  affected  side  of  the  face  reddens,  and 
the  skin  becomes  warm  (hemicrania  sympatico-tonica). 
In  another  form  of  migraine  there  is  unilateral  flushing 
of  the  face,  the  skin  appears  puffed,  its  temperature  is 
raised,  the  pupils  are  contracted,  the  temporal  arteries 
dilated,  and  sometimes  there  is  one-sided  sweating  of  the 
face  (hemicrania  sympatico-paralytica).  Although  the 
sympathetic  nerve  is  certainly  involved  in  many  cases,  it 
cannot  be  said  that  the  difficulty  of  explaining  the  char- 
acter of  the  affection  is  thereby  removed.  The  occurrence 
of  pain  has  still  to  be  accounted  for. 

Attacks  of  migraine  vary  greatly  in  duration  and 
severity  in  different  persons.  They  may  last  an  hour  or 
a  whole  day.  Nausea  or  vomiting  frequently  supervenes 
towards  the  termination,  and  is  succeeded  by  nervous 
depression  and  a  strong  inclination  to  sleep. 

In  view  of  the  chronic  course  of  migraine  it  is  advis- 
able to  be  cautious  in  regard  to  promises  of  cure. 
Patients  learn  to  submit  to  the  periodical  visitations  of 
their  sick  headache.  When  an  attack  comes  on  they 
usually  retire  to  their  rooms,  darken  the  windows,  and 
refuse  to  be  disturbed. 


MINOR  NEUROSES.  127 

Treatment.  Relief  is  often  obtained  from  cold  applica- 
tions to  the  head.  Morphia  does  not  allay  the  pain  as 
promptly  as  in  neuralgia  and  is  often  ill  borne,  as  are  all 
the  other  narcotics.  Phenacetine  and  snlfonal  are  some- 
times effective.  A  large  dose  of  quinia  at  the  commence- 
ment of  the  attack  may  succeed  in  arresting  it.  Powders 
of  guarano  in  half-drachm  doses  are  at  times  of  benefit. 
Salicylate  of  soda  is  another  remedy  worthy  of  trial. 
This  remedy  is  best  taken  in  cafe  noir.  Two  scruples 
may  be  given  at  once.  I  have  seen  some  good  effects 
from  teaspoonful  doses  of  the  effervescent  citrate  of 
caffein  every  thirty  minutes.  Inhalation  of  nitrite  of 
amyle  has  been  suggested  in  the  spastic  form  of  migraine. 

NEURASTHENIA. 

Etiology.  The  late  Dr.  Beard  of  New  York  described, 
under  the  name  of  neurasthenia,  a  functional  disorder  of 
the  nervous  system,  which  he  alleged  to  be  extremely 
common  among  the  adult  male  population  of  the  United 
States.  He  says:  "One  reason  why  neurasthenia  has 
been  so  long  neglected  is  that  the  symptoms  are  in  some 
instances  so  subtle  and  difficult  of  analysis  and  classifica- 
tion. One,  who  has  never  seen  and  carefully  examined 
a  large  number  of  cases  of  this  disease,  would  not  believe 
it  possible  that  it  should  manifest  itself  in  so  many  dif- 
ferent ways." 

Nearly  all  the  morbid  phenomena  which  are  said  to 
characterize  neurasthenia  have  usually  been  grouped 
among  different  affections,  chiefly  hysteria,  spinal  irrita- 
tion and  hypochondriasis.  It  will  hardly  be  disputed 
that  many  vague  and  ill-defined  symptoms  come  fre- 
quently   under    notice    which    cannot    be    satisfactorily 


lfS8  MANUAL   OF  NERVOUS  DISEASES. 

referred  to  those  disorders  of  uncertain  pathology  and 
inconstancy  of  clinical  features.  Experience  fully  sus- 
tains what  physiological  teachings  lead  us  to  expect,  that 
numerous  and  diversified  disorders  of  the  nervous  system 
are  directly  traceable  to  the  depressing  influences  of  phy- 
sical overexertion  and  mental  strain.  Whatever  other 
causes  may  be  assumed  to  favor  their  occurrence,  it  is  but 
fair  to  consider  nervous  exhaustion  a  fruitful  source  of 
manifold  functional  disturbances.  The  practical  impor- 
tance of  recognizing  such  a  condition  under  the  many 
disguises  it  may  assume  is  undeniable.  It  is  a  curious 
instance  of  the  change  of  meaning  that  words  undergo, 
that  the  word  ''nervous"  was  originally  employed  to 
imply  the  idea  of  vigorous,  racy,  forcible:  usage  has 
now  assigned  to  it  the  very  opposite  meaning.  We  still 
speak  of  the  "nervous  style"  of  a  writer,  but  a  feeble, 
excitable  person  is  characterized  as  being  "  nervous."  Dr. 
Beard's  happy  choice  of  the  word  ''neurasthenia,"  which 
denotes  nervous  exhaustion  or  nervous  debility,  was  at 
once  taken,  up  and  has  gained  currency  among  medical 
men.  The  adverse  criticism  which  Dr.  Beard  encoun- 
tered in  setting  up  a  new  disease  was  certainly  unde- 
served, for  neurasthenia  has  the  same  claims  as  an 
independent  nervous  affection  as  hysteria  or  spinal  irrita- 
tion. But  his  assertion  that  neurasthenia  is  par  excellence 
an  American  disease  cannot  be  sustained,  as  it  is  found  to 
be  a  widespread  nervous  affection  since  medical  observers 
have  become  better  acquainted  with  its  characteristics. 

The  greater  number  of  neurasthenic  patients  are  found 
in  our  large  cities,  the  centers  of  culture  and  traffic,  but 
also  the  places  that  incite  to  excesses.  Men  in  the  prime 
of  life  are  its  usual  victims,  and  this  fact  is  significant. 


MINOR  NEUROSES.  129 

The  expenditure  of  nerve-force  is  enormous  in  the  com- 
petition for  wealth  and  position.  The  present  state  of 
society,  especially  in  our  country,  holds  out  numerous 
and  tempting  promises  not  only  to  the  resolute  and  those 
of  a  vigorous  constitution,  but  also  to  those  of  a  weaker 
fibre  and  stamina.  There  is,  in  consequence,  a  restless, 
dissatisfied  spirit  abroad  that  strives  and  strains  for  the 
attainment  of  the  prizes  of  life.  The  unavoidable  con- 
comitants of  vexation  and  worry  of  those  not  favored  by 
a  robust  nervous  system  gradually  undermine  the  very 
roots  of  healthy  existence.  Irritability,  feverish  excite- 
ment and  discontent  unsettle  the  poise  of  the  coordinate 
powers  of  life;  then  comes  the  shock  of  disappointment, 
the  depressing  consciousness  of  failure  and  the  rebound 
from  blasted  expectations.  These  deleterious  influences, 
varied  as  they  are  in  different  individuals,  do  the  work 
silently  until  mental  and  physical  disturbances  make 
their  appearance  that  are  often  difficult  to  trace  to  their 
original  causes.  Neurasthenia  is  said  to  be  "  the  penalty 
we  pay  for  our  high-pressure  civilization,  and  for  the  wear 
and  tear  of  body  and  mind  in  the  hot  race  for  wealth 
and  distinction."  The  latter  clause  comes  certainly 
nearer  to  the  truth. 

A  predisposition  to  neurasthenia  or  an  inherited  ten- 
dency, as  in  allied  affections,  must  be  admitted  to  exist, 
for  otherwise  we  could  not  conceive  why  among  indi- 
viduals, who  are  exposed  to  the  same  order  of  influences, 
some  should  be  affected  while  others  go  free.  It  has,  for 
instance,  not  been  observed  that  shipwrecked  sailors,  or 
soldiers  undergoing  the  hardships  of  long  marches,  or 
professional  or  business  men  of  a  robust  constitution 
who  are  constantly  engaged  in  the  pursuit  of  their  labor- 

9 


130  MANUAL   OF  NERVOUS  DISEASES. 

ious  and  tr^dng  avocations,  are  picked  out  as  victims  of 
the  disorder.  If  a  certain  proportion  of  these  classes  of 
persons  become  neurasthenic  a  predisposition  must  be 
presumed  to  have  operated  that  tended  to  the  develop- 
ment of  this  morbid  condition.  But  neurasthenia,  as  has 
been  shown,  may  be  acquired  by  the  influence  of  the 
exciting  causes  that  heavily  tax  the  integrity  of  the 
nervous  system,  diminish  the  capacity  of  properly  per- 
forming its  manifold  and  delicate' functions  and  bring 
about  an  "  irritable  weakness''  that  lays  the  foundation 
of  the  functional  disorder.  It  is  hardly  necessary  to 
enumerate  all  the  more  special  exciting  causes  that  emi- 
nently tend  to  its  development. 

Clinical  History.  The  distinction  of  cerebral  and  spinal 
neurasthenia  is  based  on  the  prominence  of  certain  classes 
of  symptoms  in  individual  cases.  Cerebral  neurasthenia 
is  generally  observed  among  men  who  do  much  "  head- 
work,"  or  are  engaged  in  positions  of  great  responsibility, 
whose  extensive  and  complicated  business  aff'airs  make 
great  demands  on  their  constant  attention.  The  literary 
man,  for  example,  begins  to  find  himself  unequal  to  his 
task;  he  soon  feels  exhausted;  the  work  before  him 
becomes  irksome  and  he  is  finally  unable  to  bring  him- 
self to  carry  on  a  sustained  intellectual  eff'ort.  He  com- 
plains of  headache,  vertigo,  insomnia,  an  indifferent 
appetite,  muscular  weakness  and  a  feeling  of  general 
debility.  A  merchant  is  worn  out  by  unremitting  atten- 
tion to  business,  anxiety  concerning  heavy  ventures,  per- 
haps financial  embarrassment,  and  the  like.  His  health 
breaks  down;  he  becomes  dyspeptic;  he  feels  the  necessity 
of  rest,  which  he  denies  himself;  he  is  subject  to  frequent 
attacks  of   fainting,   his  sight  grows  weak,  and   he  has 


MINOR  NEUROSES.  ISl 

"swimming"  of  the  head.  One  of  these  symptoms  may  be 
more  obtrusive  than  the  rest,  which  fixes  his  attention 
upon  a  particular  organ  as  the  seat  of  his  trouble.  A 
hypochondriac   disposition   is   thus   apt   to   show   itself. 

A  very  singular  form  of  psychical  disturbance  some- 
tijies  develops  in  this  class  of  patients.  The  disorder 
relates  to  a  morbid  fear,  which  the  patient  is  unable  to 
suppress.  It  may  assume  different  forms,  the  most  com- 
mon being  agraphobia  (fear  of  open  places);  claustra- 
phobia  (fear  of  inclosed  places);  androphobia  (fear  of 
crowds  of  people)  and  mysophobia  (fear  of  contamina- 
tion). I  knew  of  a  gentleman,  who  had  been  unfortunate 
in  stock  speculations,  and  whose  morbid  fear  consisted  in 
the  dread  of  fatal  accidents  that  might  be  due  to  his 
negligence.  He  tortured  himself  with  the  accusation 
of  having  caused  the  death  of  an  intimate  friend  because 
on  a  cold  winter  day  he  did  not  close  the  door  of  the  sick- 
room on  his  last  visit.  He  picks  up  bits  of  fruit  parings 
he  finds  on  the  pavement  and  throws  them  into  the  gut- 
ter lest  some  one  might  slip  on  them  and  break  a  limb. 
He  stops  in  his  walk  to  fasten  a  loose  brick  on  the  pave- 
ment, and  hammers  in  nails  which  he  finds  sticking  out 
in  houses  and  fences  which  he  passes.  The  man's  intelli- 
gence is  perfectly  clear. 

The  pathophobia  in  neurasthenia  is  not  to  be  confounded 
with  hypochondriasis.  The  former  implies  an  unsubstan- 
tial dread;  the  fancied  disease  of  the  latter  is  founded 
on  a  real  morbid  sensation. 

Disturbances  of  the  special  senses  are  also  quite  fre- 
quent in  neurasthenia.  Asthenopia  often  exists,  but 
hallucination  of  hearing  is  the  most  troublesome  and 
distressing    of    this    group    of    symptoms.     A    nursing 


133  MA  NUAL   OF  NER  VOUS  DIS  EA  SES . 

woman,  who  complained  to  me  of  a  large  number  of 
neurasthenic  disorders  that  had  only  lately  begun  to 
affect  her,  consulted  me  particularly  concerning  a  distinct 
voice  that  terrified  her  almost  continually  with  the  com- 
mand to  kill  her  child.  She  was  perfect! \^  aware  of  the 
unreality  of  the  voice,  which  was  proved  by  her  desire  to 
avail  herself  of  medical  assistance. 

A  peculiar  species  of  headache,  which  may  properly  be 
called  the  "neurasthenic  headache,"  is  also  a  very  har- 
assing and  obstinate  symptom.  It  is  not  precisely  a 
pain,  but  a  sensation  as  if  the  head  were  pressed  upon  by 
a  heavy  weight,  or  distended  to  bursting.  Patients 
declare  they  will  "  go  mad  "  if  not  relieved. 

Spinal  neurasthenia  gives  rise  to  numerous  symptoms. 
The  most  prominent  and  constant  one  is  pain  in  the  back 
and  the  lower  extremities.  The  patient  comjDlains  of  an 
unaccountable  feeling  of  fatigue  even  if  he  is  inactive. 
Micturition  and  defecation  may  cause  much  discomfort. 
The  genital  function  is  often  impaired.  There  is  an 
unpleasant  feeling  of  coldness,  numbness  or  formication 
of  the  limbs  or  trunk.  Many  neurasthenic  patients  suffer 
only  from  the  minor  disorders  that  have  been  described 
and  get  little  sympathy.  The  more  severe  forms  of  the 
affection  unfit  patients  for  all  physical  and  mental 
efltbrt. 

Diagnosis.  Dr.  Beard  was  undoubtedly  correct  when  he 
laid  stress  on  the  difficulty  of  recognizing  the  existence 
of  neurasthenia.  Diagnosis  may  err  in  many  ways.  In 
the  presence  of  a  complexity  of  symptoms,  that  do  not 
agree  with  the  picture  of  a  well-known  individual  disease, 
a  particular  symptom  of  prominence  may  be  falsely 
singled  out  by  the  observer  to  which  the  rest  are  consid- 


MINOR  NEUROSES.  1S3 

ered  subordinate.  It  may  happen,  for  instance,  that 
dyspeptic  derangement  is  obtrusive,  which  suggests  serious 
disease  of  some  of  the  chylopoedic  viscera,  or  the  muscu- 
lar weakness  and  numbness  of  the  lower  extremities  may 
suggest  paraparesis.  The  diagnosis  of  neurasthenia  cer- 
tainly requires  caution,  and  often  must  be  arrived  at  by 
exclusion. 

Prognosis.  Neurasthenia  is  not  a  dangerous  affection, 
but  it  takes  a  chronic  course  and  is  subject  to  exacerba- 
tions. The  greater  number  of  patients  make  a  complete 
recovery,  while  others  of  a  neuropathic  tendency  are 
never  entirely  cured. 

Treatment.  It  is  of  the  first  importance,  in  the  treatment 
of  neurasthenia,  that  the  patient  change  the  mode  of  life 
which  led  to  his  brain  exhaustion  or  spinal  irritability. 
He  may  require  absolute  rest  and  quiet,  or  be  benefited 
by  outdoor  exercise  that  does  not  fatigue.  The  recuper- 
ative influence  of  mountain  air,  or  a  visit  to  the  seaside, 
should  be  strongly  recommended  when  the  patient  is 
much  run  down.  All  kinds  of  mental  excitement  should 
be  avoided.  He  may  require  sufficient  sleep,  a  substan- 
tial diet  and  a  judicious  course  of  tonic  remedies.  The 
nervous  dyspepsia  can  be  better  overcome  by  assuring 
the  patient  of  his  ability  to  digest  the  ordinary  dishes  to 
which  he  has  been  used  than  to  ply  him  constantly  with 
stomachic  remedies.  In  his  case  the  indigestion  is  due 
to  the  want  of  a  proper  innervation  of  the  muscular 
structure  of  the  stomach,  and  probably  the  same  fault 
affects  the  secreting  apparatus.  A  minute  direction  in 
regard  to  the  articles  of  diet  to  be  selected  only  confirms 
him  in  his  pusillanimity. 


m  MANUAL  OF  NERVOUS  DISEASES. 

Next  in  importance  is  the  moral  treatment,  differing, 
however,  from  that  followed  in  hysteria.  The  dread  and 
apprehension  of  the  neurasthenic  patient  is  to  be  allayed 
by  constant  assurance  of  the  curability  of  his  disease, 
and  confident  expressions  in  regard  to  his  progressive 
improvement  at  every  visit.  Severe  nervous  debility  in 
women  must  be  systematically  treated,  for  which  Weir 
Mitchell's  method  is  excellently  adapted. 

The  refreshing  and  invigorating  influence  of  electricity 
is  much  appreciated  by  neurasthenic  patients.  It  is  a 
constitutional  treatment  that  should  be  persistently 
employed.  The  methods  of  application  may  be  varied. 
General  faradization  and  central  galvanization  are  the 
most  effective.  In  timid  persons  it  is  preferable  to  use  the 
electric  bath  or  the  "electric  hand."  The  restoration  of 
the  muscular  vigor  is  also  assisted  by  massage.  Surf- 
baths  and  swimming  are  of  analogous  benefit. 

Symptomatic  treatment  requires  a  few  remarks. 
Habitual  constipation,  which  always  attends  nervous 
dyspepsia,  is  best  overcome  by  a  change  of  diet.  Knead- 
ing of  the  abdominal  walls  is  sometimes  quite  effective  in 
exciting  the  peristaltic  action  of  the  bowels.  Sexual 
weakness  is  benefited  by  douches  to  the  back.  Conti- 
nence should  be  advised.  Wakefulness,  which  is  a  stand- 
ing complaint  in  neurasthenia,  tempts  to  the  abuse  of 
morphia  and  chloral.  Before  even  prescribing  the  less 
powerful  hypnotics  some  other  means  may  be  found  to 
secure  sufficient  sleep.  A  warm  bath  before  bedtime  or  a 
wet  cloth  wrapped  around  the  head  is  often  effectual. 
Very  weakly  persons  unused  to  alcohol  frequently  sleep 
well  on  a  hot  rum-punch,  or  a  glass  of  ale.  The  bromide 
of  potassium  in  large  doses  occasionally  promotes  sleep. 


MINOR  NEURONES.  1S5 

A  resort  to  the  following  hypnotics  offers  much  choice. 
They  include  sulfonal,  .urethan,  paraldehyde,  canabis 
indica  and  phenacetiii-^  But  in  the  end  all  these  drugs 
disappoint.  In  fact,  the  amelioration  of  insomnia,  and 
all  the  other  symptoms  of  neurasthenia,  will  come  with 
the  general  improvement  of  the  patient. 

SPINAL   IRRITATION. 

Etiology.  Formerly,  w'hen  this  disorder  was  thought  to 
be  of  frequent  occurrence,  extravagant  notions  were 
entertained  concerning  its  importance,  as  the  common 
pathological  factor  of  a  legion  of  diseases.  Spinal  ten- 
derness is  now  known  to  attend  many  affections  of  which 
it  constitutes  an  insignificant  symptom.  Moreover,  the 
same  symptom  is  so  often  observed  in  hysterical  females 
that  neurologists  of  the  present  day  are  inclined  to  dis- 
card "  spinal  irritation"  as  an  independent  disease.  But, 
on  the  other  hand,  it  is  hardly  permissible  to  label  every 
obscure  nervous  disorder  in  females  with  the  convenient 
title,  hysteria.  The  physician  in  actual  practice  cannot 
ignore  the  fact  that  he  has  frequently  to  face  a  group  of 
symjjtoms,  which  seem  to  stand  in  no  other  relation  to 
each  other  than  their  co-existence  with  painful  vertebrae. 
The  circumstance  that  eccentric  pains  and  an  exalted 
sensibility  constitute  symptoms  aFmost  invariably  asso- 
ciated with  spinal  tenderness  tells  strongly  in  favor  of  the 
assumption  that  spinal  irritation  is  at  least  a  malady  of 
clinical  importance. 

Excessive  physical  exertion  trying  to  the  spine  is  prob- 
ably, in  many  instances,  the  exciting  cause.  Anstiesays: 
"I  believe  the  starting-point  of  the  disorder  will  very 
often  be  found  in  some  strain  or  blow  to  the  back." 


136  MANUAL  OF  NERVOUS   DISEASES. 

Clinical  History.  Patients  are  often  unaware  of  the  exist- 
ence of  tender  vertebrae  until  they  are  firmly  pressed 
upon.  The  painful  points  are  usually  limited  to  the  cer- 
vical or  upper  dorsal  region.  In  severe  cases  the  whole 
vertebral  column  appears  to  be  tender  to  the  touch. 
Areas  of  hyperaesthesia  about  the  neck  and  between  the 
shoulders  are  also  recognized. 

Neuralgiform  pains  of  a  shifting  character  are  felt  in 
different  parts  of  the  chest  and  abdominal  walls.  Their 
locality  frequently  corresponds  to  the  distribution  of  the 
sensory  fibres  that  proceed  from  the  tender  portions  of 
the  spinal  column.  A  crampy  condition  of  the  muscles 
of  the  neck  often  gives  rise  to  a  distressing  sensation  of 
choking.  There  is  sometimes  a  dry,  harassing  cough, 
attended  by  disturbed  respiration  and  cardiac  anxiety, 
which  greatly  alarms  the  patient.  Insomnia  is  much 
complained  of,  and  in  aggravated  cases  the  feeling  of 
languor  and  depression  causes  the  patient  to  seek  the 
bed  or  lounge  in  the  daytime.  As  the  disorder  is  almost 
exclusively  confined  to  the  female,  it  is  no  wonder  that 
the  menstrual  function  is  often  irregular.  It  would  be 
unprofitable  to  enumerate  all  the  "  functional  symptoms" 
that,  by  a  choice  of  phrase,  might  also  be  named  hysteri- 
cal or  neurasthenic. 

Although  spinal  irritation  is  a  chronic  disorder,  exceed- 
ingly variable  in  the  severity  and  number  of  its  symp- 
toms, hard  to  deal  with  and  prone  to  relapse,  it  nevertheless 
tends  to  recovery. 

Treatment.  As  spinal  irritation  often  occurs  in  females 
who  have  undergone  much  hardship  in  life,  both  physical 
and  mental,  or  subjected  the  nervous  system  to  debili- 
tating infiuences,  such  remedial  measures  are  to  be  rec- 


MINOR  NEUROSES.  1S7 

ommended  that  invigorate  the  general  constitution. 
Symptomatic  treatment  is  often  called  for  to  meet  special 
disturbances.  All  observers  are  agreed  that  the  alcoholic 
stimulant  is  of  decided  benefit  in  giving  relief  to  the 
manifold  ailments  of  this  disorder,  though  its  dangerous 
fascination  is  a  great  drawback  to  its  employment  as  a 
remedy.  Blistering  of  the  tender  vertebrae  should  be 
continued  until  the  pain  disappears.  The  hypera^sthesia 
often  yields  to  stabile  galvanization  of  the  affected  parts. 


CHAPTER  VIII. 

DISEASES  OF  THE  MEMBRANES  OP    THE 
SPINAL  CORD. 

Preliminary  Remarks.  Ideopathic  inflammation  of  the 
membranes  of  the  spinal  cord  is  usually  attributed  to 
the  influence  of  cold.  The  disease  is  more  frequently- 
due  to  direct  injury  of  the  vertebral  column,  or  to  exten- 
sion of  the  inflammatory  process  in  the  bones,  to  the 
meninges.  Of  greater  practical  importance  is  the  asso- 
ciated inflammation  of  the  cerebral  and  spinal  pia  mater, 
which  constitutes  the  distinctive  anatomical  change  of 
the  infectious  disease  known  as  "epidemic  cerebro- 
spinal meningitis."  Implication  of  the  spinal  meninges 
is  of  subordinate  importance  in  inflammatory  disease  of 
the  substance  of  the  cord  (meningo-myelitis).  Spinal 
meningitis  may  complicate  tubercular  cerebral  menin- 
gitis. It  sometimes  develops  in  pyaemia,  typhoid  fever 
and  the  acute  exanthemata. 

PACCHYMENINGITIS  SPINALIS. 

Suppurative  inflammation  of  the  external  surface  of 
the  dura  mater  often  arises' in  caries  of  the  vertebral  bones 
(pacchymeningitis  externa).  The  inflammation  often 
involves  the  inner  surface  of  this  membrane  and  gradually 
spreads  to  the  pia  mater  (pacchymeningitis  interna).    As 

(  138) 


MEMBRANES  OF  SPINAL   CORD.  139 

there  are  no  peculiar  symptoms  that  distinguish  the  dif- 
ferent forms  of  spinal  meningitis,  it  will  suffice  to 
describe  the  primary  acute  inflammation  of  the  spinal 
pia  mater. 

SPINAL  MENINGITIS. 

(Leptomeningitis  Spinalis  Acuta.) 

Anatomical  Changes.  The  pia  mater  in  the  early  stage  of 
the  disease  is  injected  and  thickened.  As  the  disease 
advances,  an  effusion  of  coagulable  lymph  is  thrown  out, 
which  is  most  abundant  upon  the  posterior  surface  of  the 
cord.  Later,  a  sero-purulent  or  purulent  exudation  col- 
lects in  different  parts  of  the  surface  of  the  cord,  and 
sometimes  is  found  to  cover  the  whole  length  of  this 
organ. 

Clinical  History.  In  many  cases  of  spinal  meningitis 
there  is  a  combination  of  spinal  and  head  symptoms,  due 
to  the  simultaneous  implication  of  the  cerebral  and  spinal 
pia  mater.  The  symptoms  of  spinal  meningitis  may  also 
complicate  acuter  infectious  diseases.  The  clinical  charac- 
ter of  a  primary  spinal  meningitis  is  likewise  varied  or 
modified  by  symptoms  dependent  on  inflammation  or 
the  disturbed  circulation  of  the  cord.  By  a  careful 
analysis  of  the  symptoms  in  complicated  cases  it  will  not 
be  found  difficult  to  distinguish  those  that  refer  to  the 
spinal  inflammation.  They  chiefly  consist  of  severe  pain 
in  the  baek  and  the  inferior  extremities,  accompanied  by 
stiffness  of  the  trunk  and  the  affected  limbs.  The  least 
movement  of  the  body  starts  and  increases  the  pain  and 
the  muscular  rigidity.  This  is  the  reason  why  the 
patient  is  found  lying  perfectly  still  on  his  back.     He 


L'fi  MA  y  UAL  OF  NER  VO  US  D  IS  EA  S  ES . 

shuns  every  movement  and  even  tries  to  repress  coughing 
and  sneezing.  The  voluntary  immobility  of  the  patient 
presents  the  appearance  of  loss  of  muscular  power,  but 
paralysis  is  not  a  symptom  directly  due  to  spinal  menin- 
gitis. Hypersesthesia  is  often  well  marked  and  attended 
by  increase  of  the  reflex  excitability.  The  patient  dreads 
to  be  moved  or  to  change  his  position  in  bed  in  fear  of 
bringing  on  spasmodic  movements.  In  severe  cases  he  is 
annoj'ed  by  the  opening  and  shutting  of  the  door,  and 
even  by  a  footfall  on  the  floor.  The  bladder  is  irritable 
and  the  bowels  are  confined.  There  is  always  more  or 
less  fever.  The  development  of  anaesthesia  or  paralysis 
indicates  implication  of  the  cord. 

Diagnosis.  An  uncomplicated  case  of  acute  spinal  men- 
ingitis is  chiefly  recognized  by  the  rather  sudden  onset  of 
a  febrile  affection  attended  by  rhachialgia,  rigidity  of  the 
trunk,  and  pain  and  stiffness  of  the  inferior  extremities. 
When  these  symptoms  develop  in  connection  with  those 
of  cerebral  disease,  they  are  overshadowed  by  the  far 
more  serious  import  of  the  latter  ;  and  the  same  is  true 
when  the  appearance  of  paraplegia  indicates  implication 
of  the  substance  of  the  spinal  cord.  It  is  of  importance 
to  recognize  the  grave  character  of  spinal  symj^toms  aris- 
ing in  pyaemia  or  typhoid  fever  when  the  cervical  cord 
becomes  involved.  This  occurrence  is  manifested  by  dis- 
turbance of  the  respiration,  disordered  action  of  the  lieart 
and  pupillary  changes. 

Prognosis,  Recovery  may  be  expected  in  the  primary 
form  of  acute  spinal  meningitis,  due  to  exposure  to  cold, 
but  the  prognosis  of  pacchymeningitis  and  of  that  form 
of  the  disease  accompanied  by  cerebral  symptoms  is 
exceedingly  unfavorable. 


MEMBRANES  OF  SPINAL  CORD.  Ul 

Treatment.  An  active  treatment  is  indicated  in  the 
primary  form  of  the  disease.  The  therapeutical  meas- 
ures that  tend  to  subdue  the  inflammation  include  wet 
cups  in  the  painful  regions  of  the  vertebral  column,  fol- 
lowed by  warm  or  cold  poultices.  A  saline  cathartic  is 
often  of  much  benefit,  not  only  for  moving  the  bowels, 
but  also  as  a  derivative.  This  may  be  kept  up  with 
advantage  by  small  doses  of  calomel.  The  bladder 
demands  attention.  For  the  relief  of  the  rhachialgia 
nothing  can  take  the  place  of  the  judicious  administration 
of  morj^hia.  Iodide  of  potassium  is  of  benefit  in  the 
later  stage  or  when  the  disease  is  protracted. 

HEMORRHAGE  OF  THE  SPINAL  MENINGES. 

(Spinal  Apoplexy.) 

Injury  of  the  vertebrae  is  the  usual  cause  of  extravasa- 
tion of  blood  from  the  venous  plexus  between  the  bones 
and  the  dura  mater.  Aneurisms  have  been  known  to 
burst  into  the  spinal  canal. 

The  symptoms  of  spinal  apoplexy  develop  suddenly  and 
with  great  violence.  The  pain  in  the  back  is  intense  ;  the 
patient  falls  over  as  if  shot ;  the  lower  extremities  become 
powerless  and  the  nervous  prostration  is  extreme.  After 
a  variable  time,  if  the  patient  recovers  from  the  effects  of 
the  shock,  the  group  of  symptoms  characteristic  of  spinal 
meningitis  make  their  appearance. 

CHRONIC  SPINAL  LEPTOMENINGITIS. 

Since  the*  recent  advances  in  the  more  precise  path- 
ology of  the  spinal  cord  the  existence  of  a  primary  form  of 
chronic  spinal  meningitis  has  become  exceedingly 
doubtfuL     The  possibility  of  the  acute  disease  becoming 


11,2  MA  N  UAL  OF  NER  VO  US  D  IS  EA  SES . 

chronic  is  not  disputed,  but  according  to  observation  it 
must  be  of  very  rare  occurrence.  Inflammatory  adhesions 
of  the  pia  and  dura  mater  are  often  found  in  various 
affections  of  the  spinal  cord,  but  are  of  slight  clinical 
importance. 


PACCHYMENINGITIS  CERVICALIS  HYPERTROPHICA. 

Etiology.  This  is  a  chronic  disease  of  the  cervical  dura 
mater.  It  is  met  with  in  persons  addicted  to  excessive 
use  of  alcohol,  and  is  also  attributed  to  exposure  to  cold 
and  damp. 

The  Anatomical  Change  consists  of  marked  induration  of  the 
dura  mater,  the  pia  being  only  slightly  aff'ected.  The 
thickening  of  the  membrane  irritates  and  subsequently 
compresses  the  nerve  roots.  Finally  the  motor  tract  of 
the  spinal  cord  is  involved. 

Clinical  History.  The  disease  begins  with  severe  neural- 
giform pains  in  the  occiput,  neck  and  arms.  There  is 
also  a  feeling  of  numbness  in  the  upper  extremities,  on 
which  occasionally  an  herpetic  eruption  makes  it  appear- 
ance. In  the  second  stage  an  atrophic  paralysis  develops 
in  the  muscles  of  the  forearm,  which  are  supplied  by  the 
median  and  ulnar  nerves.  In  some  cases  the  muscles  to 
which  the  musculo-spiral  is  distributed  are  also  impli- 
cated. This  gives  rise  to  a  peculiar  deformity  of  the 
hand.  The  hand  is  strongly  flexed,  the  fingers  are  on  a 
line  with  the  metacarpal  bones  and  are  flexed,  and  the 
thumb  is  bent  upon  the  palm  of  the  hand.  If  the  change 
in  the  cord  takes  a  downward  direction  the  inferior 
extremities  become  also  paralyzed  and  aucTsthetic,  but 
there  is  no  wasting  of  muscles.     The   additional   symp- 


MEMBRANES  OF  SPINAL   CORD.  US 

toms  include  painful  swelling  of  the  small  joints  of  the 
hand,  dilatation  of  the  pupils  and  troublesome  hiccough. 
Ross  reports  two  typical  cases  of  the  disease,  one  of  which 
recovered.  Joffroy  recommends  the  thermo-cautery  to 
the  back  of  the  neck. 

THROMBOSIS  OF  CEREBRAL  SINUSES. 

Besides  the  inflammatory  thrombosis  of  the  cavernous 
and  petrosal  sinus  occurring  from  extension  of  otitis  to 
the  dura  mater  another  form  of  thrombosis  is  met  with 
affecting  the  longitudinal  sinus,  which  is  seen  in  ill- 
nourished  children  and  marasmic  adults.  The  clinical 
history  of  these  cases  is  not  sufficiently  pronounced  to 
permit  of  a  certain  diagnosis.  Either  the  symj)toms 
characteristic  of  meningitis  are  prominent  or  there  is  a 
low  typhoid  condition. 


CHAPTER  IX. 

DISEASES  OF  THE  SPIXAL  COED. 

Diseases  of  the  spinal  cord  may  be  divided  into  two 
large  groups.  The  pathological  change  in  the  one  is 
more  or  less  diffused  in  the  transverse  direction  of  the 
cord,  involving  both  the  white  and  gray  substance.  This 
group  includes  the  different  forms  of  transverse  myelitis. 
The  anatomical  change  in  the  other  group  is  confined  to 
definite  tracts  of  the  cord.  This  remarkable  limitation 
of  the  lesion  gives  rise  to  special  sj^mptoms,  that  distin- 
guish the  ''  systemic  diseases"  of  the  spinal  cord. 
They  chiefly  include  locomotor  ataxia,  poliomyelitis 
anterior  acuta,  amyotrophic  lateral  sclerosis  and  pro- 
gressive muscular  atrophy.  The  clinical  peculiarities  of 
this  class  of  diseases  are  essentially  due  to  the  situation 
and  not  the  nature  of  the  lesion.  We  are  thus  enabled 
in  cases  which  do  not  correspond  to  typical  spinal  affec- 
tions to  form  a  diagnosis  concerning  the  definite  part  of 
"the  cord  which  is  involved.  The  simultaneous  or  suc- 
cessive implication  of  different  nerve  tracts  of  the  cord 
give  rise  to  combined  forms  of  spinal  disease.  This  is 
usually  dependent  on  the  extension  of  the  original 
lesion. 

(144) 


DISEASES  OF  THE  SPINAL  CORD. 


llfS 


The  following  figure  reproduced  from  Young  is  an 
instructive  diagram  illustrating  a  number  of  functional 
disturbances  of  the  spinal  cord. 


C,  Skin.  4,    Lesion    of   the   anterior    gray 

T,  Tendon.  horn. 

M,  Muscle.  5,    Lesion    of    the   antei-ior    root 

1,  Lesion  of  the  peripheral  nerve.  zone. 

2,  Lesion  of  the  posterior  root.  6,    Transverse  lesion  of  the  spinal 

3,  Lesion   of   the    posterior    root  cord. 

zone.  7,    Local   lesion   of    the    cerebral 

hemisphere. 

The  different  nerve  fibres  of  C  and  T  terminate  in  the  ganglion  cell 
of  the  anterior  gray  cornua  from  which  issues  an  efferent  nerve,  which 
connects  the  cell  with  the  muscle  M.  The  lesion  7  of  the  pyramidal 
tract  in  the  hemisphere  causes  hemiplegia  of  the  opposite  side.  The 
dotted  lines  indicate  descending  degeneration  of  the  pyramidal  tract. 
10 


U6  MANUAL  OF  NER  VOUS  DISEASES. 

Lesion  of  the  peripheral  nerve  at  1  causes  atrophic  paralysis,  loss  of 
sensation  and  abolition  of  both  kinds  of  reflexes,  but  no  paralysis. 
Lesion  of  the  posterior  root  nerve  at  2  causes  loss  of  sensation  and 
abolition  of  both  kinds  of  reflexes,  but  no  paralysis  (pacchymeningitis). 
Lesion  of  the  posterior  root  zone  at  3  causes  loss  of  tendon  reflex  only 
(locomotor  ataxia).  Lesion  of  the  anterior  graj^  nerve  at  4  causes 
atrophic  j)aralysis,  but  no  sensory  disorder  (poliomyelitis).  Lesion  of 
the  anterior  root  at  5  causes  the  same  symptoms.  Transverse  lesion 
of  the  spinal  cord  at  6  causes  paralysis  of  the  lower  extremities  with 
excess  of  both  kinds  of  reflexes. 

ACUTE  AND  CHRONIC  MYELITIS. 

Etiology.  The  usual  causes  of  ideopathic  myelitis  are 
attributed  to  physical  hardship,  especially  outdoor  work 
during  rough  weather.  It  is  much  less  certain  that 
sexual  excesses  or  violent  emotion  cause  the  disease. 
Individuals  are  affected  in  whom  the  existence  of  a  pre- 
disposing or  exciting  cause  cannot  be  ascertained.  The 
most  frequent  causes  are  injuries  to  the  vertebral  column, 
such  as  fracture,  dislocation,  penetrating  wounds,  falls, 
and  blows  on  the  back.  Another  important  factor  in  the 
causation  of  myelitis  is  compression  of  the  cord  in  caries 
of  vertebral  bones.  Secondary  myelitis  may  result  from 
suppurative  spinal  meningitis.  There  is  also  strong  evi- 
dence that  myelitis  may  be  of  syphilitic  origin. 

Anatomical  Changes.  On  inspecting  the  spinal  cord  in 
recent  cases  of  myelitis  no  marked  changes  are  seen.  An 
expert  may,  however,  recognize  in  some  places  an 
abnormal  hardness  or  softening  of  the  cord.  The  out- 
lines of  the  gray  matter  on  cross  sections  appear  less 
distinct  than  normal  and  the  white  substance  is  of  a  red- 
dish-gray color. 

Microscopic  examination  gives  more  satisfactory  evi- 
dence of  the  effects  of  the  inflammatory  process.  Staining 


DISEASES  OF  THE  SPINAL   CORD.  W 

brings  out  a  prominent  difference  between  the  healthy  and 
diseased  parts  of  the  cord.  The  nerve  fibres  in  the  latter 
are  reduced  in  number,  some  are  atrophied  and  others  have 
entirely  disappeared;  the  axis  cylinders  are  round  or 
contracted  and  have  lost  their  processes.  A  striking 
change  is  recognized  in  the  neuroglia,  consisting  of 
increase  of  connective  tissue,  which  replaces  the  destroyed 
nerve  elements.  The  "  spider  cells"  represent  the  many 
branched  nucleii  of  the  connective  tissue  cells.  Com- 
pound granular  corpuscles  are  seen  in  abundance  between 
the  meshes  of  the  neuroglia,  but  are  less  numerous  in 
old  sclerosed  parts.  Marked  changes  are  also  found  in 
the  blood-vessels;  they  are  dilated  and  congested,  this 
condition  gives  rise  to  hsemorrhagic  spots.  The  walls  of 
the  vessels  have  undergone  "  hyaline  degeneration." 
These  anatomical  alterations  usually  occupy  a  transverse 
section  of  the  cord  and  extend  for  a  very  short  distance 
in  the  longitudinal  direction  of  the  organ.  The  only  dif- 
ference in  regard  to  the  character  of  the  anatomical 
changes  of  acute  and  chronic  myelitis  is  the  unimportant 
circumstance  that  the  diseased  part  of  the  cord  in  the 
former  is  of  less  consistence.  Clinically  we  speak  of 
acute  myelitis,  when  there  is  a  rapid  development  of  the 
symptoms. 

Clinical  History.  A  description  of  the  motor  and  sensory 
disorders,  including  abnormal  reflex  action  and  implica- 
tion of  the  bladder,  the  rectum  and  sexual  functions, 
embraces  the  essential  clinical  history  of  all  forms  of 
transverse  myelitis.  The  special  symptoms  observed  in 
individual  cases  depend  on  the  particular  region  of  the 
cord  which  is  the  seat  of  the  disease. 


us  MANUAL  OF  NERVOUS  DISEASES. 

Motor  Disturbances.  The  initial  motor  symptoms  indi- 
cate the  development  of  paralysis.  The  patient  complains 
of  weakness  and  a  sensation  of  fatigue  in  the  lower 
extremities,  and  he  has  an  unsteady  gait.  Gradually  the 
weakness  of  the  limbs  increases  until  marked  paraplegia 
is  established.  These  symptoms  take  a  different  course 
when  the  upper  region  of  the  cord  is  affected.  Signs  of 
motor  irritation  are  also  observed  in  the  early  stage, 
consisting  of  the  spontaneous  occurrence  of  twitching 
and  cramp  in  the  paralyzed  muscles.  Paraplegia  is 
the  constant  and  conspicuous  symptom  of  transverse 
myelitis,  as  the  motor  tract  of  each  lateral  column  of 
the  cord  is  involved. 

Sensory  Disorders  are  not  well  marked  in  the  early 
period  of  mild  forms  of  myelitis.  Some  slight  numbness 
and  furriness  of  the  lower  extremities  is  often  present. 
At  a  later  stage  the  cutaneous  sensibility  in  these  parts 
is  impaired  and  complete  anaesthesia  is  finally  estab- 
lished. This  occurrence  indicates  implication  of  the  gray 
posterior  cornua  and  the  posterior  columns  of  the  cord. 
Total  anaesthesia  of  the  paralyzed  parts  speedily  ensues 
in  traumatic  myelitis.  In  lumbar  myelitis  the  anaes- 
thesia is  on  a  line  with  the  umbilicus  ;  in  myelitis  of 
the  lower  dorsal  region  the  anaesthesia  is  on  a  level  with 
the  lower  part  of  the  sternum  ;  in  myelitis  of  the  upper 
dorsal  region  the  anaesthesia  reaches  the  axilla,  and  in 
cervical  myelitis  the  sensibility  of  the  arms  is  impaired. 

The  Reflexes.  Both  the  cutaneous  and  tendon  reflexes 
are  morbidly  affected,  either  in  consequence  of  interrup- 
tion of  the  centripetal  paths  of  the  nerves  or  interfer- 
ence with  the  inhibitory  fibres.  In  severe  inflammation 
of  the  dorsal  or  cervical  cord  there  is  marked  increase 


DISEASES  OF  THE  SPINAL  CORD.  U9 

of  the  reflexes.  When  the  disease  involves  the  lumbar 
enlargement  the  patellar  and  cremaster  reflexes  are 
abolished. 

Disorder-  of  the  Bladder  and  the  Rectum.  Impairment 
of  the  functions  of  the  bladder  and  the  rectum  is  a  very 
common  symptom  of  myelitis.  At  the  outset  there  is  con- 
siderable vesical  irritability.  The  evacuation  of  the 
bladder  is  attended  by  a  straining  effort,  and  there  is 
often  retention  of  the  urine.  At  an  advanced  stage 
incontinence  ensues,  which  frequently  leads  to  cystitis. 
This  is  always  a  serious  complication,  as  it  threatens  the 
development  of  pyelo-nephritis.  Obstinate  constipation 
of  the  bowels  exists  from  the  beginning,  and  as  the 
paralysis  increases  the  discharges  pass  away  involun- 
tarily. 

The  sexual  function  is  weakened  early  in  severe  cases, 
and  finally  may  be  wholly  lost.  In  the  case  of  a  young 
married  man  whom  I  attended  the  myelitis,  which 
resulted  from  the  kick  of  a  vicious  mule,  had  so  far 
improved  that  the  patient  was  again  able  to  walk  with  the 
assistance  of  a  cane,  while  his  sexual  powers  still  con- 
tinued to  be  entirely  lost. 

Trophic  Disturbances.  The  paralyzed  limbs  in  disease 
of  the  dorsal  and  cervical  cord  do  not  waste.  The 
muscles  are,  however,  flabby  from  disuse.  The  electric 
reaction  is  normal.  When  myelitis  affects  the  lumbar 
cord  the  muscles  of  the  lower  extremities  atrophy  and 
manifest  the  reaction  of  degeneration. 

Vaso-Motor  Disturbances.  The  paralyzed  limbs  present 
a  mottled  appearance  or  are  cyanotic.  The  surface  is 
cool  and  oedema  appears. 


150  MANUAL  OF  NERVOUS  DISEASES. 

Bed  sores  constitute  serious  complications  in  myelitis. 
They  usually  develop  in  the  sacral  region  and  inner  side 
of  tlie  knees.  The  decubitus  is  chiefly  due  to  pressure 
and  the  effect  of  irritating  discharges  from  the  bladder 
and  rectum.  Malignant  decubitus  is  supposed  to  be  due 
to  trophic  changes. 

Psychical  Symptoms  are  absent  during  the  whole  course 
of  myelitis.  In  rare  cases  the  brain  is  involved  from 
upward  extension  of  the  disease,  which  gives  rise  to 
bulbar  symptoms. 

Changes  of  the  Pirpils  are  observed  in  cervical  myelitis. 
Sometimes  optic  neuritis  is  discovered  by  the  ophthalmo- 
scope. 

Diagnosis.  Transverse  myelitis  in  which  the  diameter  of 
the  cord  is  implicated  can  hardly  give  rise  to  diagnostic 
difficulties.  The  essential  symptoms  are  paraplegia, 
anaesthesia,  implication  of  the  sphincters  of  the  bladder 
and  rectum,  impairment  of  the  sexual  function,  absence 
of  atrophy  in  lesion  of  the  dorsal  and  cervical  regions, 
but  wasting  of  the  paralyzed  muscles  and  abnormal 
electric  reaction  in  advanced  cases  of  lumbar  myelitis. 
It  remains  yet  to  consider  the  special  symptoms  presented 
when  the  disease  attacks  different  segments  of  the  cord. 

Cervical  Myelitis.  In  myelitis  of  this  region  of  the  cord 
some  or  all  of  the  muscles  of  both  arms  and  legs  are 
paralyzed.  Atrophy  of  single  muscles  is  occasionally 
observed,  and  in  a  late  stage  also  anaesthesia.  The 
tendon  reflexes  in  the  lower  limbs  are  exaggerated  and 
there  is  disturbance  of  the  sphincters  of  the  bladder  and 
rectum.     Pupillary  changes  are  sometimes  noticed. 

Dorsal  Myelitis.     The    paraplegia    is   confined  to  the 


DISEASES  OF  THE  SPINAL  CORD.  151 

inferior  extremities,  and  eventually  anaesthesia  develops. 
There  is  no  degenerative  atrophy  of  the  paralyzed  mus- 
cles, but  increase  of  the  tendon  reflexes.  The  bladder 
and  rectum  are  involved. 

Lumbar  Myelitis.  There  is  motor  and  sensory  paralysis 
of  the  legs,  the  upper  extremities  are  free.  The  cuta- 
neous and  tendon  reflexes  are  diminished.  Sometimes 
there  is  atrophy  of  the  paralyzed  muscles  and  reaction 
of  degeneration.  The  functions  of  the  bladder,  the  rectum 
and  the  sexual  organ  are  impaired. 

Course  and  Prognosis.  Chronic  myelitis,  which  is  not  the 
continuation  of  the  acute  form,  begins  slowly  and  in  an 
insidious  manner.  The  vague  parsesthetic  sensations  and 
rheumatoid  pains  in  the  limbs,  the  slight  muscular  weak- 
ness, the  occasional  vesical  trouble  and  slight  impairment 
of  the  sexual  function  may  at  the  beginning  cause  little 
anxiety  to  the  patient.  Gradually  the  paresis  increases, 
although  the  cutaneous  sensibility  be  still  intact  until 
the  paralysis  is  completely  established.  Chronic  myelitis 
may  remain  stationary  for  years  and  even  for  a  lifetime. 
Some  improvement  may  occasionally  be  observed,  but 
recoveries  are  extremely  rare.  A  fatal  termination  is 
threatened  on  the  occurrence  of  cystitis  or  the  appearance 
of  malignant  bed  sore. 

Treatment.  The  faintest  suspicion  of  a  history  of  syphilis 
indicates  the  prompt  employment  of  the  specific  remedies. 
This  causal  treatment  is  of  course  to  be  abandoned  if  not 
followed  by  improvement  after  a  reasonable  time.  Ergo- 
tine  is  recommended  by  Brown-Sequard.  This  remedy 
may  be  of  service  in  the  early  stage.  Russel  Reynolds 
speaks  favorably  of  the  tinct.  ferrichloride.  Among  the 
other  internal  remedies  generally  employed  in  myelitis  are 


152  MANUAL  OF  NERVOUS  DISEASES. 

included  the  iodide  of  potassium,  strychnia  and  nitrate  of 
silver. 

Very  little  must  be  expected  from  other  curative 
measures  in  confirmed  myelitis.  Electricity  may  be  of 
considerable  benefit,  though  it  can  as  little  restore  degen- 
erated structure,  as  any  other  remedy.  Galvanization 
promises  most.  The  method  recommended  is  to  place 
two  large  electrodes  on  the  vertebral  column  near  the 
supposed  seat  of  the  disease  in  the  cord,  and  to  pass 
through  it  a  stabile  or  slow  labile  current  of  medium 
strength.  The  position  of  the  electrodes  may  be  varied  in 
different  sittings.  Stimulation  of  the  paralyzed  muscles 
with  the  constant  and  interrupted  current  is  also  to  be 
practiced.  The  electric  brush  is  adapted  for  the  anaes- 
thesia. The  bladder  and  rectum  may  be  separately  gal- 
vanized with  suitable  electrodes.  A  warm  bath,  which 
should  never  be  over  98'  F.,  is  an  excellent  means  of 
relieving  many  unpleasant  sensations  attending  the  paral- 
ysis. It  often  relieves  tremor  and  twitching  of  the  para- 
lyzed muscles.  The  warm  mud  baths  of  the  Arkansas 
hot  springs  stand  in  much  reputation  for  the  treatment  of 
paraplegia. 

Attention  to  the  functions  of  the  bladder  and  the  rectum 
is  required  throughout  the  whole  course  of  the  disease. 
To  prevent  retention  of  urine  nothing  can  replace  the  use 
of  the  catheter.  Severe  cystitis  is  treated  with  chlorate 
of  potassium  freely  diluted,  benzoic  acid  and  liquor 
potassie. 

Bed  sores  are  often  prevented  by  cleanliness  and  the 
proper  adjustment  of  the  bedclothes  so  as  to  avoid  the 
formation  of  folds  and  wrinkles.  A  water  or  air  cushion 
may  become  necessary.     The   abrasions  of  the  skin  are 


DISEASES  OF  THE  SPINAL    CORD.  153 

sometimes  satisfactorily  treated  with  a  combination  of 
castor  oil  and  balsam  of  copaiba  spread  on  a  piece  of 
thick  linen  cloth.  Suppurating  sores  are  best  treated 
with  iodoform  liniment. 

Constipation  should  be  overcome  by  an  appropriate 
diet  and  enemata.  The  restlessness  and  insomnia  of  old 
paralytics  may  sometimes  be  best  relieved  by  a  hot  rum 
punch  at  night. 


ACUTE   ASCENDING  PARALYSIS. 

Landry's  Disease. 

This  is  a  peculiar  form  of  paralysis  which  was  first 
described  by  Landry  and  has  since  been  often  seen  by 
other  observers.  The  etiology  of  the  disease  is  obscure. 
It  attacks  apparently  healthy  persons  and  men  more 
frequently  than  women. 

Clinical  History.  The  development  of  the  paralysis  is 
always  announced  by  premonitory  symptoms.  For  the 
first  few  days  the  patient  complains  of  headache,  loss  of 
appetite,  a  dragging  sensation  in  the  limbs,  pain  in  the 
back  and  some  fever.  Quite  suddenly  one  leg  becomes 
paralyzed,  then  the  other,  next  the  trunk  and  lastly  the 
hands  and  arms.  Voluntary  movement  of  the  lower 
extremities  is  completely  abolished,  and  the  paralyzed 
limbs  are  flaccid.  In  some  cases  the  reflexes  and  the 
electric  excitability  remain  intact,  but  usually  the  tendon 
reactions  are  diminished  or  entirely  abolished  and  the 
electric  excitability  is  lost. 

The  sensory  disorders  are  insignificant.  Anaesthesia  is 
very  seldom  obseived.     There  is  occasionally  some  ting- 


15  Jt  ^lA  N  UAL   OF  NER  VO  US  D  IS  EA  S  ES . 

ling  or  numbness  of  the  fingers.  None  of  the  cranial 
nerves  are  affected.  The  legs  are  sometimes  oedematous 
and  often  covered  with  perspiration.  The  bladder  and 
rectum  are  not  implicated. 

A  favorable  turn  of  the  symptoms  after  the  patient  has 
lingered  from  two  to  four  weeks  may  lead  to  complete 
recovery.  A  fatal  termination  is  imminent  if  the  disease 
in  its  upward  progress  involves  the  medulla  oblongata. 
Respiration  becomes  then  difficult,  the  movements  of  the 
diaphragm  are  diminished,  and  before  death  ensues  the 
paresis  frequently  affects  the  lips  and  soft  palate.  But 
patients  have  been  known  to  rally  even  after  the  appear- 
ance of  these  formidable  symptoms  and  to  make  a  tedious 
recovery. 

In  the  absence  of  anatomical  changes  affecting  the 
nervous  system,  it  has  been  conjectured  that  the  disease 
may  be  of  an  infectious  origin.  The  character  of  the 
premonitory  symptoms  and  the  attending  fever  lend  sup- 
port to  this  view. 

The  Diagnosis  rests  on  the  development  of  a  paralysis 
commencing  in  the  feet  and  rapidly  extending  upwards. 
Primary  multiple  neuritis  presents  similar  clinical  pecu- 
liarities, but  this  affection  is  distinguished  by  marked 
sensory  irritation,  consisting  of  violent  pain  in  the  affected 
parts.  These  symptoms  are  absent  in  acute  ascending 
paralysis. 

Treatment.  The  disease  suggests  the  treatment  of  acute 
myelitis.  In  addition  to  the  usual  remedies  recommended 
in  that  disease  it  may  be  of  service  in  the  early  stage  to 
apply  wet  cups  along  the  vertebral  column. 


DISEASES  OF  THE  SPINAL   CORD.  155 

SPINAL  PARALYSIS  FROM  GROWTHS  AND  CAVITIES 
IN  THE  CORD. 

Paraplegia  is  in  rare  instances  caused  by  tumor  of 
the  spinal  cord  and  more  seldom  still  by  an  aneurism 
making  its  way  into  the  spinal  canal.  These  forms  of 
"pressure  paralysis"  are  accompanied  by  violent  shooting 
pains  and  stiffness  of  the  limbs  and  the  usual  symptoms 
characteristic  of  transverse  myelitis.  Unilateral  paralysis 
develops  when  the  tumor  is  confined  to  one  side  of  the 
cord. 

Cavities  found  in  the  spinal  cord  arise  from  dilatation 
of  the  central  canal  (hydromyelia),  or  develop  near  it 
(syringo-myelia ) . 

It  is  impossible  to  diagnose  the  existence  of  a  tumor  or 
cavity  of  the  cord  during  the  life  of  the  patient.  These 
lesions  give  rise  to  varieties  of  myelitis  according  to  their 
situation.     Small  cavities  develop  no  symptoms. 

Unilateral  Lesion  of  the  Cord. 
Traumatism  is  the  usual  cause  of  this  form  of  spinal 
paralysis.  The  peculiarity  of  the  paralysis  consists  in 
this,  that  motor  paralysis  is  confined  to  the  side  of  the 
lesion,  and  anaesthesia  to  the  opposite  part  of  the  body. 
Physiology  furnishes  an  explanation  of  this  phenomenon. 

CONCUSSION  OF  THE  SPINAL  CORD. 

Railway  Spine. 
Although  this  is  usually  considered  a  surgical  disease, 
yet  symptoms  of  an  essential  nervous  character  may 
develop  in  the  course  of  weeks  or  months  after  the  imme- 
diate effects  of  the  injury  have  passed  off.  Since  the  intro- 
duction of  railroad  travel,  accidents  affecting  the  spinal 


156  MA  N  UA  L   0  F  NER  VOUS  DISEASES. 

cord  in  consequence  of  concussion  have*  become  frequent 
and  have  given  rise  to  suits  for  damages.  Erichsen  in  his 
little  book  on  this  subject  proposed  the  name  ''railway 
spine"  to  characterize  spinal  concussion  in  which  there  is 
absence  of  gross  injury  to  the  vertebrae,  such  as  fracture, 
dislocation  or  hemorrhage.  A  knowledge  of  the  finer 
changes  taking  place  in  the  spinal  cord  from  concussion, 
independent  of  a  palpable  lesion,  is  not  claimed.  The  infer- 
ence that  this  organ  is  in  a  morbid  condition  is  based  on 
the  appearance  of  a  group  of  symptoms  that  are  evidently 
spinal.  Such  an  inference  is  strengthened  by  the  anala- 
gous  fact  that  no  coarse  lesion  of  the  nervous  system  has 
been  found  in  many  cases  of  death  occurring  a  few  hours 
after  concussion  of  the  brain. 

Clinical  History.  The  symptoms  that  develop  or  become 
troublesome  by  their  persistence  after  the  accident  are 
chiefly  subjective,  and  for  this  reason  admit  of  different 
interpretations.  They  mainly  consist  of  a  general  mus- 
cular weakness  and  painful  sensations  in  diffent  parts  of 
the  body.  There  is  no  actual  paralysis,  but  many 
patients  are  quickly  tired  out  from  standing  and  walking. 
The  gait  is  stiff,  slow  and  dragging,  and  often  requires 
the'aid  of  a  stick  or  crutch.  The  pain  is  mostly  felt  in 
the  back  and  limbs,  and  there  is  a  sensation  of  constric- 
tion about  the  trunk.  Numbness  of  the  tips  of  the  fingers 
is  frequently  complained  of  and  on  closer  examination 
well-marked  anaesthsia  will  be  found  in  different  areas  of 
the  skin.  In  some  cases  there  is  contraction  of  the  field 
of  vision.  The  tendon  reflexes  are  diminished  or  may  be 
entirely  abolished.  If  cerebral  symptoms  are  present 
they  generally  consist  of  headache,  dizziness,  attacks  of 


DISEASES  OF  THE  SPINAL   CORD.  157 

faintness,  ringing  in  the  ears,  specks  before  the  eyes  and 
often  nervous  irritability  and  mental  depression. 

Recovery  or  much  improvement  may  be  expected  from 
treatment  in  favorable  cases.  The  trouble  is,  however, 
usually  protracted  and  tends  to  develop  a  serious  spinal 
affection.  The  hope  of  having  made  a  fortunate  escape 
from  the  consequences  of  the  concussion  is  disappointed. 
Paresis  and  anaesthesia  of  the  legs  and  disturbance  of  the 
functions  of  the  bladder  and  rectum  and  sexual  organ 
render  it  apparent  that  the  previous  mild  symptoms 
have  culminated  in  the  establishment  of  a  grave  spinal 
disease.  The  occurrence  of  difficulty  of  speech,  insomnia, 
defective  memory  and  general  nervous  prostration  indi- 
cate cerebral  complication.  Though  casual  improve- 
ment may  still  take  place  it  soon  becomes  clear  that  the 
patient  is  continually  losing  ground.  Emaciation  and 
marked  weakness  are  manifest  and  the  fatal  termination 
is  hastened  by  the  occurrence  of  any  incidental  complica- 
tion. It  may  be  fairly  assumed  that  the  concussion  has 
finally  given  rise  to  grave  lesion  of  the  spinal  cord  and 
brain. 

The  Diagnosis  of  spinal  concussion  should  not  be  lightly 
made,  for  symptoms  showing  irritation  of  the  spinal  cord 
and  functional  motor  disturbances  may  be  due  to  a  dif- 
ferent cause,  or  may  be  simulated.  The  circumstance 
that  the  initial  symptoms  are  all  subjective  and  partake 
of  the  hysterical  or  neurasthenic  character  render  it 
incumbent  to  make  a  thorough  examination.  The  judg- 
ment in  regard  to  the  early  symptoms  should  take  into 
consideration  the  influence  of  fright,  the  exaggeration  of 
impressible   individuals  and  a  possible  interested  motive. 


158  MANUAL   OF  NERVOUS  DISEASES. 

Due   weight  must,  however,  be  given  to  the  condition  of 
the  reflexes  and  other  physical  signs  of  disease. 

The  Treatment  of  the  condition  that  persists  after  the 
shock  has  passed  off  consists  of  rest  in  bed,  cold  spong- 
ing, followed  by  friction  of  the  back  and  galvanization  of 
the  vertebral  column  and  of  the  limbs.  General  faradi- 
zation is  also  of  benefit.  The  judicious  administration 
of  iodide  of  potassium,  ergotine  and  strychnia  may  be 
found  of  service. 


CHAPTER  X. 
SYSTEMIC  DISEASES  OF  THE    SPINAL  COED. 

Loco-motor   Ataxia. 

{Tabes   Dorsalis.) 

Etiology.  Loco-motor  ataxia  is  a  striking  example  of 
the  class  of  systemic  diseases  of  the  spinal  cord.  It  is  a 
chronic  disease,  anatomically  distinguished  by  degenera- 
tion of  the  posterior  columns  of  the  spinal  cord  and 
clinically  marked  by  peculiar  motor  symptoms.  The 
predisposing  and  exciting  causes  are  usually  referred  to 
a  hereditary  tendency,  physical  and  mental  overexertion 
and  sexual  excesses;  but  the  uncertainty  in  regard  to 
these  alleged  etiological  factors  must  be  admitted.  The 
disease  appears  with  greater  frequency  in  men  than  in 
women,  and  usually  in  the  middle  period  of  life.  The 
fact  has  been  ascertained  as  the  result  of  recent  investi- 
gations that  a  very  large  percentage  of  ataxic  patients 
have  had  a  history  of  syphilis.  Fournier  rates  the 
proportion  at  75  per  cent;  Erb  as  high  as  90  per  cent. 
Other  observers  give  lower  figures,  but  the  probability 
of  a  connection  between  ataxia  and  syphilis  is  very 
strong.  Secondary  or  tertiary  symptoms  are  only 
occasionally  observed  in  ataxic  patients.  The  objection 
raised   against   the  supposed   relation  existing   between 

(159) 


wo  MANUAL  OF  NERVOUS  DISEASES. 

ataxia  and  syphilis  is  the  circumstance  that  the  ana- 
tomical changes  in  ataxia  differ  histologically  from  those 
characteristic  of  syphilitic  degeneration.  It  is  neverthe- 
less highly  probable  that  loco-motor  ataxia  is  somehow 
connected  with  a  syphilitic  influence.  In  female  tabetic 
patients  a  history  of  syphilitic  infection  can  be  made  out 
in  nearly  every  case. 

Anatomical  Changes.  Inspection  of  the  spinal  cord  in 
patients  who  have  died  in  the  advanced  stage  of  loco- 
motor ataxia  discovers  considerable  alteration  of  this 
organ.  A  streak  of  gray  discoloration  running  along  the 
whole  length  of  the  shrunken  cord  is  seen  through  the 
pia  mater.  This  membrane  at  the  under  surface  is 
thickened.  On  a  cross-section  it  is  noticed  that  the 
smallness  of  the  cord  is  due  to  atrophy  of  the  posterior 
columns.  These  parts  appear  thin  and  flattened  and  are 
distinguished  from  other  portions  of  the  cord  by  their 
darker  color.  The  posterior  cornua  and  posterior  nerve 
roots  present  sometimes  a  similar  appearance. 

The  microscope  shows  unequal  distribution  of  the 
degeneration.  In  the  lumbar  cord  the  morbid  change  is 
well  marked  in  the  middle  and  posterior  portion  of  the 
posterior  columns.  Nearly  the  whole  of  the  posterior 
columns  of  the  dorsal  cord  is  degenerated.  Goll's  col- 
umn in  the  cervical  cord  is  chiefly  implicated,  and  also 
fibres  of  the  posterior  root  zones  that  enter  Burdach's 
column  in  the  lumbar  cord.  Areas  of  degeneration  are 
also  seen  in  the  gray  matter  of  the  posterior  cornua,  and 
many  of  the  medullated  fibres  of  Clarke's  column  have 
disappeared.  The  degeneration  in  advanced  cases  can 
be  traced  to  peripheral  nerves  of  the  posterior  nerve 
roots,  especially  in  the  trunk  of  the  sciatic.      It  is  note- 


,S'  rS  TEM IC  DISEAS  ES  SPINAL   CORD.  161 

worthy  that  every  case  of  loco-motor  ataxia  presents  the 
same  anatomical  change  in  the  symmetrical  nerve  tracts  of 
the  spinal  cord  that  subserve  the  same  physiological 
functions. 

The  pathological  process  in  the  diseased  structure  is  a 
primary  degenerative  atrophy  of  the  nerve  elements  and 
an  increase  of  the  connective  tissue.  The  grayish  color 
of  the  posterior  columns  is  due  to  the  loss  of  the  medul- 
lary sheaths.  A  few  fat  granules  and  numerous  corpora 
amylacea^  are  also  found  in  old  cases. 

Clinical  History.  It  is  convenient  in  considering  the 
clinical  history  of  loco-motor  ataxia  to  divide  it  into 
three  stages,  although  there  is  great  variation  in  the 
intensity  of  the  symtoms,  their  order  of  occurrence  and 
their  combination. 

1.  The  stage  of  sensory  irritation.  Usually  the  disease 
develops  in  an  insidious?  manner  and  this  condition  may 
continue  for  a  considerable  length  of  time  before  the 
more  significant  symptoms  make  their  appearance. 
Patients  begin  to  complain  of  wandering  pains  in  the 
lower  extremities,  which  they  are  apt  to  ascribe  to  rheu- 
matism. The  arms  and  back  are  often  similarly  affected. 
But  the  most  characteristic  symptom  at  the  early  stage 
is  the  occurrence  of  darting,  lancinating  or  lightning-like 
pains  in  the  legs.  These  pains  are  of  great  intensity  and 
recur  at  first  at  irregular  periods,  but  as  the  disease 
advances  they  are  almost  continuous.  Sometimes  "stab- 
bing" pains  are  felt  in  the  joints.  A  headache  like 
migraine  is  also  a  common  tabetic  symptom.  The 
"girdle  sensation"  is  often  well  pronounced.  The  patient 
has  the  feeling  as  if  a  rope  were  tightly  fastened  around 
his   trunk  or  abdomen,  or  there  is  a  feeling  as  if  the 


102  M  A  N  UAL  OF  N  E  R  V  0  U  S   DISEASES. 

calves  of  the  legs  or  the  insteps  of  the  feet  were  tightly 
bandaged. 

The  other  sensory  disturbances  are  less  constant. 
Certain  areas  of  the  skin  are  found  hypera^sthetic.  The 
patient  is  especially  very  sensative  to  changes  of  tem- 
perature. Some  degree  of  numbness  in  the  tips  of  the 
fingers  is  often  present.  On  examining  a  patient  it  may 
be  found  that  at  first  he  does  not  feel  the  prick  of  a  pin, 
but  a  few  minutes  afterwards  he  feels  pain  at  the  point  of 
contact.  The  tactile  sensation  is  frequently  abnormal. 
On  being  touched  in  one  place  he  may  declare  that  he  felt 
two  simultaneous  impressions.  It  is  only  in  the  later 
stage  of  the  disease  that  evident  anaesthesia  and  anomalies 
of  the  muscular  sense  can  be  satisfactorily  recognized. 
Disorders  of  the  bladder  and  rectum,  which  are  usually 
well  marked  in  advanced  cases,  are  often  conspicuous  at 
an  early  period,  and  the  same  maybe  said  of  the  sexual 
function. 

Ocular  symptoms  sometimes  appear  at  an  early  stage. 
Immobility  of  the  pupils  is  often  noticed,  especially  the; 
"  Argyle  Robertson  symptom,"  or  the  pupils  are  very 
much  contracted.  Paralysis  of  ocular  muscles  is  not  as 
fr(^quently  observed  at  the  beginning  and  may  only  be 
temporary.  A  diplopia  may  disappear  and  not  return. 
Dimness  of  sight,  contraction  of  the  field  of  vision  ter- 
minating in  total  blindness,  also  belong  to  the  occasional 
initial  symptoms.  The  latter  complication  of  the  disease 
is  due  to  optic  atrophy.  In  a  small  percentage  of  cases 
auditory  symptoms  develop  consisting  of  tinnitus,  deaf- 
ness and  vertigo  as  in  Menier's  disease. 

2.  The  ataxic  stage.  The  appearance  of  the  ataxic  symp- 
toms may  l)e  considered  the  second  stage  of  the  disease. 


S  Y S  T E M IV  DI S E A  S  E S   S  P  J N AL    CO  U  I) .  /';? 

There  is  no  paralysis,  for  the  patient  is  able  to  offer  great 
resistance  to  an  attempt  to  bend  the  limb,  but  there  is  inco- 
ordination of  movements.  The  mechanism  which  adjusts 
and  controls  the  harmonious  action  of  muscles  in  carrying 
out  intended  movements  is  impaired.  The  act  of  standing 
is  insecure  and  uncertain,  the  gait  is  oscillating  and  totter- 
ing. In  the  act  of  rising  from  his  seat  the  patient  has 
much  difficulty  to  gain  a  secure  footing,  which  he  tries 
to  overcome  by  bracing  himself  Avith  his  hands.  These 
irregularities  of  motion  are  of  much  importance  and 
may  be  observed  before  the  disease  has  made  much 
progress.  The  patient  himself  may  have  noticed  that 
his  body  sways  when,  for  instance,  he  bathes  himself  in 
the  morning.  When  mounting  steps  he  is  apt  to  stumble. 
He  has  a  straddling  gait,  he  places  his  feet  wide  apart 
to  gain  greater  support  ;  in  lifting  them  he  raises  them 
too  high  and  they  come  down  on  the  ground  with  a  stamp. 
On  making  a  quick  turn,  as  in  the  military  "  face  about," 
he  loses  his  equilibrium.  In  standing  he  seeks  for  support 
by  leaning  against  something,  and  in  walking  he  needs  a 
stick.  There  are  many  ways  of  testing  the  existence  of 
inco-ordination.  When  the  patient  lies  on  his  back  and 
is  told  to  touch  the  knee  of  one  leg  with  the  heel  of  the 
other  foot  he  makes  several  attempts  before  he  succeeds. 
When  he  is  asked  to  throw  one  leg  over  the  other  he 
makes  too  wide  a  sweep  with  the  raised  leg. 

The  impaired  cutaneous  sensibility  and  disorder  of  the 
muscular  sense  constitute  the  causes  of  "Romberg's 
symptom."  If  the  patient  closes  his  eyes  whilst  stand- 
ing his  body  begins  to  reel;  he  is  unable  to  sustain  his 
center  of  gravity,  and  if  not  supported  he  would  fall 
over.     It  is  interesting  to  observe  the  influence  of  sight 


1(;4  MA  .V  UA  L  OF  NER  VOUS  DIS  EA  S  ES . 

in  supplementing  the  loss  of  control  over  the  movements 
of  locomotion.  The  patient  fixes  his  eyes  on  every  step 
he  takes.  The  upper  extremities  are  much  less  affected. 
There  is  sometimes  a  want  of  precision  in  manipulations, 
especially  in  those  that  require  nicety  of  execution. 
Patients  experience  much  difficulty  in  buttoning  a  sleeve 
or  threading  a  needle.  Anaesthesia  is  frequently  well 
marked;  at  least  some  of  the  different  qualities  of  com- 
mon sensation  are  either  blunted  or  entirely  abolished. 
There  is  impairment  of  tactile  and  muscular  sensibility. 
This  explains  the  fact  that  patients  cannot  tell  the 
position  of  their  limbs  when  in  bed  or  in  the  dark. 
A  more  constant  sensory  symptom  is  an  abnormal  feeling 
of  the  nature  of  numbness.  Patients  compare  it  to  a 
feeling  of  furriness,  especially  experienced  in  the  soles  of 
the  feet,  as  if  they  were  standing  on  a  soft  cushion  or  on  a 
bag  filled  with  air.  In  the  hands  the  sensation  produces 
the  impression  of  being  covered  with  gloves.  There  is 
also  a  morbid  sensitiveness  to  changes  of  temperature. 

The  cutaneous  reflexes,  as  a  general  rule,  are  normal^ 
but  the  aholition  of  the  i^atellar  tendon  reaction  is  such  a 
constanl'symptom  of  loco-motor  ataxia  that  it  constitutes 
one  of  the  most  important  diagnostic  signs  of  this  dis- 
ease. Exceptional  cases  may  be  met  with  in  which 
many  of  the  tabetic  symptoms  are  present,  while  the 
patellar  reflex  is  not  deficient.  This  circumstance  does 
not  diminish  the  gigniijcance  of  the  absence  of  the  knee 
jerk.  On  the  other  hand  there  are  healthy  individuals  in 
whom  the  patellar  tendon  reflex  can  be  but  faintly 
elicited,  which  of  itself  would  not  be  considered  an 
abnormal  condition. 

Trophic  disorders  are  not  conspicuous  in  ataxia.     An 


S  YS  TEM  [  C   I)  IS  EASES  SPINAL  CORD.  165 

eruption  of  pemphigus  or  herpes  sometimes  appears  on 
the  inferior  extremities  along  the  course  of  painful 
nerves.  Occasionally  perforating  ulcer  of  the  foot  develops. 
Of  greater  interest  is  the  occurrence  of  painful  swelling 
of  one  of  the  large  joints.  The  ^^  arthropathic  iaheiiqve'" 
either  affects  the  hip  or  the  knee  joint. 

Intercurrent  attacks  of  gastralgia,  nausea  and  vomiting 
— the  cnsis  gastrique — are  observed  in  many  cases  of 
ataxia.  Laryngeal  crisis  consists  of  the  occurrence  of 
severe  dyspnoea  and  spasmodic  cough.  Violent  lumbar 
pain,  resembling  an  attack  of  nephritic  colic,  is  less  fre- 
quently observed.  Periodical  acceleration  of  the  pulse  is 
sometimes  noticed  during  the  course  of  the  disease. 

Incoordination.  The  peculiar  motor  disturbance  which 
is  such  a  prominent  symptom  of  loco-motor  ataxia,  brings 
up  the  consideration  of  the  nature  of  coordination  and 
the  mechanism  that  subserves  this  physiological  function. 
It  is  now  generally  understood  that  co-ordination  is  the 
machine-like  execution  of  .movements  by  which  different 
muscles  are  brought  into  harmonious  action.  The  vol- 
untary impulse  incites  the  special  movements,  but  con- 
sciousness is  not  concerned  with  the  action  of  the 
individual  muscles.  The  exercise  of  the  will  is  all  that 
is  necessary  to  set  the  muscles  into  action  to  carry  out 
the  purposed  movement.  The  mode  in  which  co-ordina- 
tion is  established  we  may  learn  from  the  efforts  of  a 
child  ^vhen  it  begins  to  walk,  or  when  we  atttempt  new 
and  complicated  movements.  We  call  into  play  our 
tactile  sense  and  our  sense  of  sight,  and,  above  all,  our 
past  experiences  of  graduating  our  muscular  energy  in 
accomplishing  a  desired  act.  In  other  words,  we  make 
use  of  the  "  muscular  sense"  in  co-ordinating  our  move- 


KUi  M  A  N  U  A  L   O  F  NERVOUS   DI S  EASE  S. 

ments.  Gradually  an  organic  connection  is  established 
between  certain  nervous  elements,  so  that  consciousness 
is  no  longer  engaged  in  the  movements  after  they  have 
once  been  incited  by  the  will.  Although  the  existence  of 
centers  and  conducting  paths  of  co-ordination  cannot  be 
anatomically  demonstrated,  yet  there  is  strong  reason  to 
infer  that  such  exist  in  the  spinal  cord  and  are  implicated 
by  the  lesion  that  gives  rise  to  loco-motor  ataxia.  We 
have  seen  that  an  ataxic  patient  resorts  again  to  the  aid 
of  the  sense  of  sight  to  relieve,  in  a  measure,  the  loss  of 
co-ordination. 

3.  The  Paralytic  Stage.  Numerous  ataxic  patients  suc- 
cumb to  some  intercurrent  disease,  so  that  they  are 
spared  the  wretched  condition  of  helplessness  which 
marks  the  paralytic  stage.*  As  in  all  severe  affections  of 
the  spinal  cord  that  tend  to  a  fatal  termination,  paraplegia 
sets  in  attended  by  bedsores  and  nephritic  complications. 

Diagnosis.  Loco-motor  ataxia,  when  fully  established, 
presents  such  clearly  cut  clinical  features  that  diagnosis 
meets  with  no  difficulty.  At  an  early  stage,  when  the 
neuralgiform  pains  in  the  inferior  extremities  constitute 
the  most  conspicuous  symptom,  diagnosis  may  be  doubt- 
ful. It  is  well  to  remember  that  persistent  or  paroxysmal 
pain  in  both  legs,  especially  if  attended  with  eye  symp- 
toms and  vesical  trouble,  should  always  raise  suspicion 
of  serious  spinal  disease;  and  if  the  patellar  reflex  is 
much  diminished,  or  absent,  the  diagnosis  of  loco-motor 
ataxia  is  certain. 

Prognosis.  Experience  confirms  the  bad  prognosis, 
which  may  be  a  priori  entertained  of  a  disease  marked 
by    a  progressive  destroying  lesion.     Recoveries  if  they 


S  Y  S  T  E  MIC   DIS  E  A  S  E  S   S  P  I  .V  A  L   CORD.  167 

ever  occur,  are  extremely  rare.  Still  the  forecast  need 
not  be  absolutely  gloomy,  for  loco-motor  ataxia  some- 
times assumes  a  mild  type,  and,  under  favorable  condi- 
tions, life  may  be  prolonged. for  many  years.  The  course 
of  the  disease  is  very  chronic,  though  occasionally  serious 
symptoms  develop  rapidly.  Much  can  be  done  for  the 
relief  of  the  patient  in  palliating  the  severity  of  the  pain 
in  the  limbs  and  other  symptoms  as  they  arise,  which 
sustains  his  hope  and  courage. 

Treatment.  The  early  recognition  of  the  disease  affords 
the  opportunity  of  adopting  an  appropriate  treatment, 
with  the  expectation  at  least  of  effecting  some  improve- 
ment, if  not  arresting  its  advance.  The  patient  should 
consider  himself  an  invalid,  and  abandon  any  avocation 
that  calls  for  much  physical  and  mental  exertion. 

An  energetic  anti-syphilitic  treatment  in  the  early 
stages  is  indicated  if  there  should  be  the  least  suspicion 
of  the  venereal  taint.  P]nough  would  be  gained  in  check- 
ing the  advance  of  the  disease,  although  the  mercury 
and  the  iodide  of  potassium  be  ''found  wanting"  for  the 
removal  of  the  mischief  that  has  already  occurred. 

Different  methods  of  electric  treatment  are  recom- 
mended. An  ascending  constant  current  may  be  passed 
through  the  cord  in  the  manner  that  has  been  mentioned 
for  the  treatment  of  chronic  myelitis.  Another  method 
consists  in  brushing  the  skin  of  the  back  with  a  strong 
faradic  current  for  five  or  ten  minutes.  Peripheral  gal- 
vanization is  often  of  benefit  in  allaying  the  pain  in  the 
limbs  and  the  irritation  of  the  bladder.  The  methods  of 
electric  treatment  may  be  varied,  but  whichever  is 
selected  should  be  kept  up  for  months. 

TJte  Suspension  Treatment.  An  estimate  of  the  merits  of 


^  7^  ^sj^'^f^-  "^^^^^^^  '- 

^VHz/j     /t—J^/<t'Ji^A^t^     /CC^/t^A^^^      *^>*^  ^4,,?*^^     U^-fy^y^      rJCU^ 

A168        AlANUAL  OF  NERVOUS  BISWASES.  '       . 

the  suspension  treatment  in  ataxia,  recently  introduced"' 
into  practice  by  Charcot,  can  hardly  yet  be  decided  upon, 
although  in  many  of  the  reported  cases  the  improvement 
was  incontestible.  Further  experiments  will  determine 
whether  the  benefit  derived  from  this  treatment  is  a  per- 
manent one  or  not.  Suspension  is  made  by  Sayre's  well- 
known  apparatus.  It  is  advisable  to  commence  with 
half-minute  suspensions,  and  then  according  to  the  sus- 
ceptibility of  the  patient  they  may  gradually  be  pro- 
longed to  the  maximum  of  four  minutes  every  other  day. 

Nerve-.itretching  of  the  sciatic  for  the  relief  of  the 
pains  often  produces  a  good  effect,  though  usually  it  is 
transient. 

Internal  remedies  are  indicated  on  the  same  general 
principles  that  call  for  their  employment  in  the  treatment 
of  myelitis.  The  nitrate  of  silver  is  highly  recommended. 
One-fourth  of  a  grain  in  pill  is  the  usual  dose  to  begin 
^,  y  j^with.  It  is  given  three  times  a  day  before  meals. 
rP/^t^'^  Symptomatic  treatment  is  often  indicated,  more  par- 
ticularly for  the  mitigation  of  the  pains  in  the  limbs,  for 
which  hardly  any  other  remedy  but  morphia  will  suffice. 
Vesical  trouble  also  requires  attention.     ^ 

HEREDITARY    ATAXIA. 

F"riedrich's  Disease. 

This  very  rare  form  of  ataxia  occurs  far  more  fre- 
quently in  young  females  than  in  males.  There  is  no 
initial  stage  of  pain.  It  begins  with  ataxia  of  the 
inferior  extremities  and  soon  extends  to  the  arms.  The 
abolition  of  the  tendon  reflexes  is  observed  in  most 
cases.     The  cutaneous  sensibility  remains  intact.     There 


S  YS  TEM IC  D  IS  E  A  S  ES  S  P  IN  A  L   COR  D.  PJ9 

is  no  vesical  disturbance  nor  affection  of  sight.  A 
peculiar  defect  of  speech  develops  during  the  course  of 
the  disease,  which  appears  to  be  due  to  inco-ordinate 
action  of  the  lips  and  tongue.  The  disease  runs  a  very 
chronic  course  and  finally  atrophic  paralysis  of  the 
extremities  is  established.  The  anatomical  change  con- 
sists of  disease  of  the  posterior  and  lateral  columns  of  the 
spinal  cord.     Treatment  is  unsuccessful. 

POLIOMYELITIS    ANTERIOR    ACUTA. 

(Infantile  Spinal  Paralysis.) 

Etiology.  This  disease  was  described  by  older  writers 
under  the  name  of  "the  essential  paralysis  of  children."  It 
occurs  in  early  childhood  between  the  ages  of  six  months 
and  four  years.  Healthy  children  are  as  likely  to  be 
attacked  as  those  of  a  sickly  constitution.  Some  observers 
conjecture  that  the  disease  is  of  an  infectious  nature.  It  is 
not  identical  with  the  forms  of  paralysis  seen  after 
attacks  of  diphtheria,  scarlatina  and  measles. 

Anatomical  Changes.  The  character  of  the  anatomical 
change  in  recent  cases  appears  to  be  an  acute  inflamma- 
tion of  the  anterior  cornua  of  the  spinal  cord.  In  old 
cases  the  cornua  are  found  in  the  condition  of  atrophic 
degeneration,  implicating  to  some  extent  the  white  sub- 
stance in  their  vicinity.  The  degenerated  cornua  are 
transformed  into  a  dense  tissue  from  which  many  of  the 
ganglion  cells  have  disappeared.  A  secondary  degenera- 
tion involves  the  anterior  nerve  roots,  that  correspond 
either  to  the  cervical  or  lumbar  cord,  according  as  the 
upper  or  lower  extremities  had  been  affected  with  atrophic 
paralysis. 


170  MA  N  UAL  OF  NER  VO  US  DISEA  SES . 

Clinical  History.  The  disease  in  the  majority  of  cases 
begins  with  a  sudden  onset  of  acute  symptoms.  A  high 
grade  of  fever  develops,  accompanied  with  headache, 
delirium  and  stupor,  which  continues  with  brief  intermis- 
sions for  a  few  days  or  much  longer.  Sometimes  the 
initial  symptoms  are  of  a  mild  character  and  brief  duration. 
After  their  subsidence  or,  in  some  cases  while  apparently 
the  child  is  in  good  health,  the  little  patient  is  seen  to  have 
lost  the  use  of  one  or  both  of  the  lower  extremities  or  the 
paralysis  is  more  extensive.  The  arms  or  some  mus- 
cles of  the  trunk  may  at  the  beginning  be  involved 
but  very  soon  the  affection  becomes  limited  to  one  leg 
or  much  less  frequently  to  one  arm.  The  paralysis  in 
the  leg  is  often  confined  to  the  muscles  supplied  by  the 
peroneal  nerve.  The  general  health  of  the  child  does  not 
seem  to  be  aflfected  and  the  paralysis  usually  improves 
up  to  a  certain  point  and  then  becomes  stationary  and 
frequently  permanent.  There  is  marked  flaccidity  of  the 
paralyzed  muscles  from  the  beginning.  Gradually  they 
atrophy  and  often  to  an  extreme  degree.  The  atrophy 
may  be  concealed  by  an  abundant  deposit  of  fat. 

Sensory  disoi'ders  are  absent  during  the  whole  course 
of  the  disease.  The  functions  of  the  bladder  and  the  rec- 
tum are  rarely  afFected. 

Reflex  action  of  the  paralyzed  muscles  is  much  dimin- 
isiied  or  entirely  abolished. 

The  electric  excitability  shows  marked  changes  in  the 
course  of  the  few  weeks  next  succeeding  the  onset  of  the 
disease.  The  faradic  reaction  of  nerves  and  muscles  is 
rapidly  lost  and  the  reaction  of  degeneration  is  clearly 
manifest.     For  the  next  two  or  three  months  an  increase 


SYSTEMIC  DISEASES  SPINAL  CORD.  171 

of  the  galvanic  contractility  of  the  muscles  is  sometimes 
observed,  which  then  diminishes  and  is  finally  lost. 

The  surface  of  the  paralyzed  limbs  is  cyanotic  or  mot- 
tled and  the  skin  is  flabby  and  cold.  Shortening  of  the 
affected  limb  frequently  results  from  arrested  growth  of 
the  bones.  The  relaxed  condition  of  the  ligaments  of  the 
joints  and  the  lack  of  muscular  support  allows  of  unusual 
passive  motion  of  the  paralyzed  limb.  The  deformities 
which  at  a  late  period  develop  are  partly  produced  by  the 
predominant  action  of  the  antagonistic  muscles  and 
partly  by  the  weight  and  position  of  the  limb.  In  this 
manner  the  different  forms  of  'club  foot"  develop.  In 
bad  cases  the  stunted,  withered  limb  is  reduced  to  a  use- 
less appendage  of  the  body. 

DiagQOSis.  Retarded  development  in  small  children 
may  be  confounded  with  some  of  the  symptoms  of  spina, 
paralysis.  These  children  are  slow  in  learning  to  walk 
and  exhibit  much  awkwardness  in  their  movements  dur- 
the  period  of  their  growth;  but  there  is  no  history  of 
acute  symptoms,  no  real  paralysis,  nor  muscular  atrophy. 

The  distinction  from  other  forms  of  paralysis  in  chil- 
dren can  easily  be  made  if  we  remember  that  the  essen- 
tial features  of  the  spinal  type  are  an  acute  onset,  a 
flaccid  paralysis  joined  with  atrophy,  loss  of  the  reflex 
action,  and  the  reaction  of  degeneration,  with  retained 
sensibility. 

The  temporary  paralysis  of  children  described  by  Ken- 
nedy can  be  usually  traced  to  exposure  and  is  a  mild  affec- 
tion that  disappears  in  the  course  of  a  few  weeks. 

Prognosis.  After  the  acute  stage  has  passed  off  the 
prognosis  is  entirely  favorable  as  regards  danger  to  the 
life  of  the  patient,  but  the  complete  restoration  of  the 


172  M  A  N  UA  L   0  F  NERV  O  US   Dl  S  EASES. 

motor  function  is  very  doubtful.  If  the  paralysis  does 
not  continue  to  improve  after  the  first  few  months,  little 
further  improvement  must  be  expected.  By  a  judicious 
and  persevering  course  of  treatment  during  the  first  years 
it  may  stili  be  possible,  as  experience  has  shown,  to 
induce  a  noticeable  change  for  the  better  in  the  paralyzed 
parts. 

Treatment.  When  called  upon  to  treat  the  acute  stage 
of  the  disease  those  therapeutical  measures  will  be  indi- 
cated that  are  usually  employed  to  subdue  febrile  excite- 
ment and  to  quiet  the  nervous  system.  The  recognition 
of  the  true  state  of  the  case  at  that  period  is  difficult. 

Galvanization  holds  out  the  best  prospect  in  the  treat- 
ment of  the  paralysis.  The  most  approved  method  is  to 
place  a  large  electrode  on  the  vertebral  column  in  the. 
region  of  the  cervical  cord  if  an  arm  is  paralyzed,  and  to 
the  upper  dorsal  region  if  a  leg  is  affected.  The  other 
electrode  is  applied  to  the  paralyzed  nerves  and  muscles 
or  dabbed  over  them.  At  first  a  constant  current  of 
medium  strength  is  used,  which  is  gradually  increased 
in  intensity.  During  the  electrization  the  current  may 
occasionally  be  reversed.  Sometimes  the  kathode  and 
then  the  anode  should  be  slowly  passed  over  the  affected 
muscle.  A  sitting  should  last  from  two  to  five  minutes 
and  be  repeated  every  other  day  or  more  frequently. 
Local  faradization  of  the  muscles  is  often  of  decided 
benefit.  p]lectric  treatment  to  be  of  any  avail  must  be 
carried  out  with  persistence. 

Some  benefit  is  derived  from  passive  exercise  of  the 
paralyzed  limb,  and  this  is  best  accomplished  by  massage. 
It  is  possible  that  this  procedure  may  prevent  or  at  least 
improve    deformities  of  the    limb.     The   good    effects  of 


S  rs  TEMIC  D  IS  EA  S  ES  SPINAL  CO  R  D .         17S 

various  liniments  and  embrocations,  if  they  have  any, 
are  probably  due  to  the  vigorous  friction  that  accom- 
panies their  use. 

Good  results  are  occasionally  obtained  from  the  use  of 
brine  baths  during  the  Summer  months.  A  brine  bath 
may  be  improvised  by  dissolving  a  few  pounds  of  sea  salt 
in  a  tub  of  tepid  water. 

An  orthopedic  apparatus  will  be  often  found  necessary 
to  facilitate  walking. 

Internal  remedies  are  of  little  use.  It  is  recommended 
to  give  hypodermic  injections  of  strychnia  from  oV  to  h 
grain  until  its  physiological  effects  are  produced. 


ACUTE  AND  CHRONIC  POLIOMYELITIS  IN  ADULTS. 

A  form  of  spinal  atrophic  paralysis  identical  in  ana- 
tomical and  c]inical  characters  with  the  disease  occur- 
ring in  children,  as  described  in  the  foregoing  section, 
has  been  repeatedly  observed  in  adults.  The  acute 
symptoms  are  far  less  marked.  At  first  the  patient 
complains  of  muscular  weakness  in  the  lower  extremities, 
and  a  few  days  later  he  is  unable  to  walk.  After  a 
short  time  the  arms  are  similarly  affected  and  become 
also  paralyzed.  Extensive  atrophy  of  the  paralyzed 
muscles  ensues,  followed  by  loss  of  the  electric  excita- 
bility. In  severe  cases  the  degenerative  reaction  is  man- 
ifest and  the  cutaneous  reflexes  are  lost.  In  exceptional 
cases  the  muscles  of  the  neck,  the  tongue,  the  lips  and 
the  pharynx  are  attacked.  There  are  no  sensory  disturb- 
ances, and  the  functions  of  the  bladder  and  rectum 
remain  normal.  After  the  complete  development  of  the 
paralysis    there  is    a    halt   in    the    disease   for   months. 


nJ^  MA  iV  UAL   0  F  XER  V  0  US  D  IS  EA  SES. 

Improvement  gradually  takes  place,  and  the  paralysis 
may  finally  disappear;  oftener,  however,  recovery  is" 
imperfect  and  the  patient  is  more  or  less  disabled  for 
life. 

Further  investigations  are  required  to  determine 
whether  the  symptoms  which  have  been  described  are 
really  dependent  on  a  poliomyelitis.  They  certainly 
bear  a  close  resemblance  to  those  of  multiple  neuritis. 

SPASTIC   SPINAL   PARALYSIS. 

(Tabes  Dorsal  Spasmodique,     Primary  Lateral 
Sclerosis.) 

Although  paresis  of  the  lower  extremities,  increased 
muscular  tension  and  exaggeration  of  the  reflexes  con- 
stitute a  group  of  symptoms  differing  from  other  well- 
known  forms  of  spinal  disease,  it  cannot  be  said  that  the 
anatomical  basis  of  this  combination  of  symptoms  has 
as  yet  been  satisfactorily  determined  ;  but  they  strongly 
point  to  implication  of  the  lateral  columns  of  the  cord. 
Autopsies  of  cases  that  had  presented  the  clinical  char- 
acters of  spasmodic  paralysis  do  not  always  show  evi- 
dences of  disease  of  these  columns.  In  amyotrophic 
lateral  sclerosis  there  is  a  class  of  symptoms  that  include 
spasmodic  paralysis  of  the  inferior  extremities,  but  they 
appear  in  association  with  muscular  atrophy,  and  bulbar 
phenomena,  dependent  on  extensive  destruction  of  the 
pyramidal  tract.  Spasmodic  forms  of  paralysis  are  met 
with  in  chronic  hydrocephalus,  transverse  myelitis  of  the 
upper  dorsal  and  cervical  cord,  tumor  of  the  same  regions 
of  the  cord,  multiple  sclerosis  and  hydromyelia. 

Etiology.  The  exciting  cause  of  ordinary  spastic  spinal 
paralysis  is  unknown.     It  occurs  more  frequently  in  men 


S  YS  TEMIC  T)  IS  EA  S  ES  S  PIN  A  L   CO  R  D .  175 

than  in  women,  and  usually  develops  about  the  middle 
period  of  life. 

Clinical  History.  The  essential  symptoms  of  spinal  spas- 
tic paralysis  consist  of  a  more  or  less  paretic  condition  of 
the  lower  extremities  and  exaggeration  of  the  tendon 
reflexes,  especially  the  patellar  and  the  ankle  clonus.  In 
many  cases  there  only  exists  a  slight  muscular  weakness 
of  the  limbs,  while  in  others  the  paralysis  is  pronounced 
and  extensive.  But  the  chief  characteristic  of  the  dis- 
ease relates  to  disturbance  of  motion  that  depends  on 
stiffness  and  contracture  of  the  muscles.  When  the 
reflex  actions  are  excessive  any  passive  movement  of  the 
inferior  extremities,  even  their  own  weight,  as  when  they 
hang  free  over  the  edge  of  the  bed,  brings  on  contractions. 
The  rigidity  of  the  flexors  opposes  the  bending  of  the 
knees.  Plantar  flexion  is  sometimes  so  strong  that  the 
soles  of  the  feet  cannot  be  raised  from  the  floor.  At 
times  the  contractions  are  attended  by  such  violent 
tremor  that  the  limbs  and  the  trunk  are  shaken. 

The  exaggeration  of  the  reflexes  is  especially  conspic- 
uous when  the  patient  attempts  to  walk.  The  muscu- 
lar tension  is  then  so  great  that  flexion  of  the  limbs 
becomes  very  difficult,  which  causes  the  characteristic 
"spastic  gait."  In  consequence  of  the  stiff'ness  of  the 
legs  the  patient  has  much  trouble  to  raise  his  feet;  they 
seem  to  cling  to  the  ground,  and  in  bringing  them  for- 
ward the  toes  make  a  scraping  noise.  As  the  stiff'ened 
muscles  oppose  the  elevation  of  the  leg,  the  patient  helps 
himself  by  rotating  the  pelvis,  first  on  one  side,  then  on 
the  other.  This  produces  a  waddling  gait.  Sometimes 
the  calf  muscles  contract  so  strongly  that  the  patient 
stands  on  tiptoe  and  can  only  advance  with  a    sort   of 


no  MA  NUAL  OF  NER  VO  US  D I  SEA  S  ES . 

hopping  movement.  He  appears  to  be  walking  on  stilts. 
The  tip  of  the  foot  catches  on  little  inequalities  of  the 
ground;  he  constantly  stumbles  and  is  always  in  danger 
of  falling.  At  last  the  gait  is  reduced  to  a  mere  drag- 
ging of  the  legs,  and  the  body  requires  support  to  keep  it 
erect.  The  patient,  on  becoming  bedridden,  finds  it  even 
impossible  to  sit  up  on  account  of  stiffness  of  the  legs. 
Sometimes  late  in  the  course  of  the  disease  the  trunk  and 
upper  extremities  become  also  involved.  The  spastic 
condition  of  the  hand  and  fingers  is  then  quite  apparent. 

The  cutaneous  reflexes  and  electric  excitability  rarely 
show  any  alteration.  Sensory  disorders  are  absent.  The 
functions  of  the  bladder,  the  rectum  and  sexual  organs 
remain  normal. 

The  Prognosis  in  all  cases  of  confirmed  spastic  paralysis 
is  unfavorable.  The  disease  is  always  chronic,  but  unac- 
companied by  pain. 

The  Treatment  is  the  same  as  that  of  chronic  myelitis. 

AMYOTROPHIC  LATERAL  SCLEROSIS. 

For  the  first  accurate  description  of  this  disease  we  are 
indebted  to  Charcot  and  loff^roy.  A  typical  case  pre- 
sents a  group  of  well-defined  symptoms.  The  distinctive 
anatomical  changes  include  degeneration  of  the  pyramidal 
tract  of  the  lateral  columns  of  the  spinal  cord,  and  degen- 
erative atroph}^  of  the  ganglion  cells  of  the  anterior 
cornua  and  certain  nerve  nuclei  of  the  medulla. 

Etiology.  The  cause  of  the  disease  has  been  attributed 
to  violent  physical  exertions,  but  nothing  of  a  positive 
character  is  known  concerning  its  etiology.  The  male 
sex  is  more    frequently  affected  than  the  female.     The 


S  YSTE  M IC  n  ISEAS  ESS  P  IN  AL   CORD.         1 77 

disease  usually  makes  its  appearance  between  the  ages  of 
thirty-five  and  forty-five  j^ears. 

Anatomical  Changes.  A  cross-section  of  the  spinal  cord,  in 
advanced  cases,  shoAvs  a  simple  degeneration  of  the  whole 
pyramidal  tract  of  the  lateral  columns  of  the  cord,  includ- 
ing both  its  crossed  and  uncrossed  portions.  The  sclerosis 
also  involves  the  ganglion  cells  of  the  anterior  horns, 
the  pons,  the  crura,  internal  capsule,  and  often  some  of  the 
nerve  nuclei  in  the  floor  of  the  fourth  ventricle.  Cases  are 
also  reported  in  which  the  degeneration  had  implicated 
ganglion  cells  of  the  central  convolutions.  The  nerve 
nuclei  in  the  medulla  which  are  most  prominently  affected 
are  the  hypoglossus  and  the  spinal  accessory.  The  patho- 
logical change  in  some  cases  appears  to  involve  the  whole 
motor  tract  from  the  center  to  the  periphery.  The  nerve 
fibres  and  cells  of  the  diseased  structures  are  atrophied 
and  many  of  the  nerve  elements  have  disappeared. 
There  is  an  increase  of  the  connective  tissue  and  slight 
alteration  of  the  blood-vessels,  but  these  are  secondary 
changes.  Destruction  of  the  nerve  tissues  in  the  cord 
and  the  medulla  are  due  to  an  identical  pathological 
process.  The  same  system  of  nerves  is  involved  in  every 
case. 

Clinical  History.  The  encroachment  of  the  disease  is  first 
noticed  in  one  arm.  The  patient  feels  an  unusual  degree 
of  fatigue  in  the  limb.  Soon  after  the  oither  arm  is  simi- 
larly affected  and  this  paretic  condition  of  the  limbs 
gradually  increases.  Wasting  of  the  muscles  of  the  hand 
and  fingers  is  the  next  symptom,  commencing  in  the 
balls  of  the  thumb  and  the  little  linger.  This  is  suc- 
ceeded by  atrophy  of  the  interossii  and   extensors  of  the 

12 


i:S  M  A  S  U  A  L    n  f  .\  E  R  V  0  US   D I S  EA  S  ES . 

forearm.  The  Hexurs  also  become  affected,  Liit  in  a 
slighter  degree.  Among  the  muscles  of  the  upper  arm 
the  triceps  and  the  deltoid  show,  more  wasting  than 
the  biceps  and  the  muscles  of  the  shoulder.  In  the 
course  of  a  few  months  the  atrophy  also  invades  the 
inferior  extremities,  but  to  a  less  extent.  The  spastic 
symptoms  are  very  prominent  and  as  well  marked  as  those 
described  in  the  foregoing  section.  Although  the  dis- 
turbance of  motion  is  influenced  by  muscular  weakness, 
the  chief  difficulty  of 'locomotion  is  due  to  spasmodic 
stiffness  of  the  legs,  brought  on  by  excessive  tendon 
reaction.  The  patellar  tendon  reflex  is  easily  elicited  and 
is  very  energetic.  Ankle  clonus  is  almost  continually 
kept  up  by  exaggerated  reflex  excitability  of  the  calf 
muscles.  On  testing  the  reflex  reactions  in  the  upper 
extremities  an  equal  increase  of  reflex  excitability  will 
be  noticed.  A  slight  tap  on  the  end  of  the  radius  causes 
vigorous  reflex  contractions  of  the  biceps  and  triceps. 
Spasmodic  contractions  of  the  hands  and  arms  some- 
times develop  spontaneously  in  the  late  stage  of  the 
^disease. 

The  sensibility  continues  unchanged  and  the  cutane- 
ous reflexes  show  no  marked  alteration.  ^Ficturition  and 
•defecation  remain  normal. 

A  new  set  of  symptoms  develop  at  a  later  period. 
Speech  and  deglutition  become  difficult.  This  constitutes 
■the  third  and  last  stage  of  the  disease.  The  tongue  and 
lips  are  now  attacked  with  atrophy.  The  articulation  of 
words  is  indistinct  and  swallowing  is  much  impeded.  It 
is  noticed  that  the  tongue  trem])ies  and  twitches  and  shows 
irregularities  upon  its  surface.  The-  puckering  of  the 
mouth  for  the  acts  of  suckintr,  ])lowing  and  whistling  is 


S  YS  TEMIC  DISEA  SESSPIJS^A  L   COUD.         119 

nnicli  impaired.  Difficulty  of  deglutition  interferes  with 
the  introduction  of  a  sufficient  quantity  of  food  and  the 
embarrassment  of  the  respiration  finally  leads  to  a  fatal 
termination. 

All  the  symptoms  of  amyotrophic  lateral  sclerosis 
depend  on  the  disturbance  of  the  physiological  functions 
of  the  pans  of  the  nervous  system  which  are  involved  in 
the  degenerative  change.  The  paretic  and  spasmodic 
phenomena  are  due  to  the  destructive  lesion  of  the  great 
motor  tract  in  the  lateral  columns  of  the  spinal  cord,  the 
muscular  atrophy  corresponds  to  the  lesion  of  the  ante- 
rior gray  horns,  and  the  bulbar  symptoms  accord  with 
the  implication  of  the  nerve  nuclei  in  the  medulla.  In 
explanation  of  the  exaggerated  reflex  contractions,  it  may 
be  fairly  assumed  that  they  depend  either  on  irritation  of 
reflex  loops  in  the  cord  that  are  intact  or  on  failure  of 
inhibition. 

Diagnosis.  Amyotrophic  lateral  scleroses  i)resents  an 
assemblage  of  symptoms  which  makes  its  distinction 
from  allied  diseases  an  easy  matter.  The  co-existence  of 
muscular  atrophy,  increase  of  the  tendon  reflexes,  the 
bulbar  symptoms,  and  the  absence  of  sensory  and  vesical 
disturbance  constitute  reliable  diagnostic  points. 

The  Prognosis  must  be  considered  as  exceedingly  unfa- 
vorable. The  tendency  of  the  disease  to  a  fatal  termina- 
tion has  never  yet  been  influenced  by  any  method  of 
treatment. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Wasting  Palsy. 
Etiology.     Individuals   in   the   prime    of    life,   who    are 
actively  engaged  in  occupations   that  call  for  hard  physi- 


ISO  MA  N  UA  L  0  F  NER  V  0  US  D  fS  EA  S  ES . 

cal  exertions,  are  thought  to  be  especially  liable  to  wast- 
ing palsy,  but  often  the  exciting  cause  is  unknown.  Cases 
in  which  a  hereditary  tendency  can  be  traced  belong  ta 
another  class  of  muscular  atrophy.  The  disease  is  some- 
times observed  to  follow  S3'philis  and  acute  infectious 
diseases,  though  probably  the  muscular  atrophy  in  cases 
of  this  kind  is  not  the  genuine  spinal  disease. 

Anatomical  Changes.  We  owe  to  Duchenne  and  Aran  the 
first  excellent  description  of  progressive  muscular  atro- 
phy, but  to  Cruveilhier  belongs  the  merit  of  having  rec- 
ogaized  the  spinal  origin  of  this  disease.  He  located  the 
morbid  alteration  in  the  anterior  gray  cornua  of  the 
spinal  cord.  Opinions  were  still  divided  in  regard  to  the 
correctness  of  Cruveilhier's  statement,  for  other  eminent 
observers  considered  wasting  palsy  a  disease  of  the 
muscles,  until  Lockhart,  Clarke  and  Charcot  succeeded 
in  demonstrating  the  spinal  origin  of  the  disease.  This 
view  is  now  generally  accepted.  The  gradual  atrophy  of 
the  muscles  which  follows  a  regular  type  corresponds 
to  degenerative  changes  of  peripheral  motor  nerves, 
motor  nerve  roots  and  ganglion  cells  of  the  anterior  gray 
cornua.  There  is  a  high  degree  of  probability  that 
progressive  muscular  atrophy,  amyotrophic  lateral  scle- 
rosis and  bulbar  paralysis  are  of  an  identical  patho- 
logical nature.  The  anatomical  difference  between 
these  separate  diseases  rests  solely  on  the  circumstance 
that  in  each  the  lesion  is  localized  in  a  definite  portion  of 
the  cerebro-spinal  axis.  A  peculiar  form  of  muscular 
atrophy  of  a  myopathic  character  will  be  considered 
later. 

The  lesion  in  the  spinal  cord  is  most  evident  in 
the  anterior  gray  cornua  of  the  cervical  region.     Numer- 


.S'  Y  S  T  E  M IC  DISEASES-SPI N  A  L   C  ORD.         181 

ous  ganglion  cells  have  disappeared  and  others  are 
much  atrophied.  Fine  connective  tissue,  studded  with 
.spider  cells,  has  replaced  the  neuroglia.  The  lateral 
columns  are  perfectly  normal.  Anterior  nerve  roots 
and  nerve  fibres  corresponding  to  the  degenerated 
portions  of  the  anterior  horns  are  also  affected.  Micro- 
scopical examination  of  the  shrunken,  pale  muscles 
shows  diminution  and  a  waxy  or  fatty  condition  of  the 
muscular  fibres.  The  stria  are,  however,  still  retained. 
The  interstitial  connective  tissue  of  the  atrophied  mus- 
cles is  always  increased  and  a  deposit  of  fat  is  interposed 
between  the  remaining  muscular  fibres.  In  this  condi- 
tion of  the  muscles  the  reaction  of  degeneration  is 
manifest. 

Clinical  History.  The  first  sign  of  the  insidious  develop- 
ment of  wasting  palsy  is  atrophy  of  the  small  mus- 
cles of  the  hand,  usually  the  hypothenar  eminences. 
No  other  symptom  at  the  beginning  is  experienced  by  the 
patient  except  difficulty  in  performing  certain  movements. 
The  atrophy  alters  the  position  of  the  ball  of  the  thumb 
and  approximates  it  to  the  second  metacarpal  bones. 
Gradually  a  further  deformity  of  the  hand  occurs  from 
the  wasting  of  the  interossii  and  the  lumbricalis  muscles, 
such  as  is  seen  in  ulnar  paralysis.  The  next  point  of 
attack  is  the  extensors  of  the  forearm,  or  the  atrophy 
jumps  to  the  muscles  of  the  shoulder.  The  arm  grad- 
ually loses  its  natural  contour  as  the  dift'erent  muscles 
become  affected  with  atrophy,  and  finally  appears  thin 
and  wasted.  In  the  upper  arm  it  is  always  the  deltoid 
which  first  atrophies;  then  comes  the  biceps,  the  triceps 
holding  out  the  longest.  If  the  atrophy  is  much  advanced 
in  the  upper  extremities  the  arms  hang  dangling  by  the 


is:  M  A  X  UAL   O  F  K  E  R  V  O  U  S   1)  I S  E  A  S  E  S  . 

sides  as  if  suspended  by  a  string,  and  nothing  appears  to 
remain  of  the  shoulders  but  the  projecting  acromion  and 
coronoid  processes.  In  their  turn  the  muscles  of  the  back,, 
the  chest  and  abdomen  become  also  more  or  less  affected, 
those  of  the  lower  extremities  being  but  rarely  attacked. 
A  curious  configuration  of  the  body  is  produced  when  there 
is  an  irregular  wasting  of  the  muscles,  only  a  part  of  a 
large  muscle  being  atrophied,  while  its  next  neighbor  is 
intact.  The  bellies  of  the  sound  muscles  strangely  con- 
trast with  the  grooves  left  by  the  wasted  muscles.  Bones 
and  tendons  become  prominent  in  situations  where  the 
volume  of  the  muscles  is  diminished. 

Corresponding  with  the  extent  of  the  atrophy  there  is 
a  functional  weakness  of  the  muscles  which  does  not 
amount  to  true  paralysis,  though  the  patient  is  finally 
reduced  to  a  pitiable  state  of  helplessness.  For  a  long 
time  he  is  still  capable  of  carrying  out  movements  by 
calling  into  action  supplementary  muscles  that  yet  retain 
their  structural  integrity.  A  striking  instance  of  this 
phenomenon  I  observed  in  the  case  of  a  so-called 
"living  skeleton."  The  trapezius  was  much  atrophied 
so  that  the  head  often  dropped  forward,  but  he  contrived 
to  put  it  straight  again  by  a  violent  jerk  and  retain  it  in 
position  l.)y  means  of  the  deep  muscles  of  the  neck.  On 
attempting  to  rise  from  his  seat  he  had  the  trick  of 
giving  his  body  a  sudden  twist  that  brought  him  to  his 
feet.  Tn  this  case  the  lower  extremities  were  much 
atrophied,  and  to  some  extent  also  the  pectoralis  major, 
the  serratus  and  other  muscles  of  the  back. 

In  addition  to  the  atrophy  and  impaired  functions  of  the 
muscles  they  are  also  affected  by  fibrillary  twitching 
and     tremor.      These    symptoms    disappear    when    the 


S  Y  S  T E  M  I C '    I)  1 S  E  A  S  E  S-  S  I'f  S  A  L    C  O  R  I>.  IS-3 

atrophy  becumes  complete.  The  muscular  tremor  can  be 
easily  excited  by  giving  a  slight  blow  to  the  bellies  or 
tendons  of  the    muscles. 

The  electric  exploration  of  the  diseased  muscles  varies 
in  results.  In  general  it  is  found  that  the  electro-muscu- 
lar contractility  diminishes  in  proportion  to  the  extent  of 
the  atroph^^  So  long  as  there  are  some  of  the  muscular 
fibres  left  contractions,  though  feeble,  can  be  obtained. 
A  con:ipletely  atrophied  muscle,  or  one  which  is  mostly 
replaced  by  infiltrated  fat,  ceases  to  give  responses  to 
either  current.  Increased  galvanic  excitability  is  some- 
times observed,  and,  on  the  other  hand,  a  decided  dimi- 
nution of  electric  reaction  is  occasionally  noticed  in 
muscles  before  atrophy  is  perceptible. 

The  tendon  reflexes  of  the  superior  extremities  are 
much  diminished,  in  striking  contrast  to  their  increased 
reaction  in  amyotrophic  lateral  sclerosis.  This  difference 
is  due  to  the  circumstance  that  in  the  latter  disease 
degeneration  of  the  pyramidal  tract  occurs  prior  to  the 
atrophy,  which  \»  not  the  case  in  progressive  muscular 
atrophy.  When  the  lower  extremities  are  involved  there 
is  absence  of  the  patellar  reflex. 

Trophic  changes  are  infrequent  and  of  little  signifi- 
cance when  they  occur.  If  the  atrophy  is  attended  with 
much  fatty  in-filtration  it  may  be  difficult  to  recognize 
the  wasting,  but  the  atrophied  muscles  have  a  soft  and 
pasty  feeling  and  the  electric  excitability  is  diminished. 
The  skin  is  sometimes  cyanotic,  thick  and  fissured,  and 
the  nails  are  brittle. 

In  very  few  cases  a  relatively  sudden  development  of 
the  atrophy  is  preceded  by  vague  rheumatic-like  pains, 
but   sensory    disorders,    as    a   general    rule,    are    absent 


IS ;  M  A  X  U  A  L   0  F  X  E  R  V  0  US  D I S  EASES. 

throughout  the  whole  course  of  the  disease.  The  cuta- 
neous sensibiHty  is  preserved  and  the  sphincters  of  the 
bladder  and  rectum  are  unaffected. 

The  symptoms  of  bulbar  paralysis  make  their  appear- 
ance in  protracted  cases  in  consequence  of  the  extension 
of  the  disease  from  the  anterior  cornua  to  the  nerve 
nuclei  of  the  medulla  oblongata,  that  innervate  the 
muscles  of  the  tongue,  the  lips,  the  pharynx  and  the 
respiratory  muscles.  AVe  have  here  the  identical  com- 
plication which  more  frequently  and  at  an  earlier  date 
occurs  in  amyotrophic  lateral  sclerosis. 

Diagnosis.  Errors  of  diagnosis  can  be  easily  avoided  if 
the  marked  peculiarities  of  genuine  progressive  muscular 
atrophy  be  kept  in  view.  They  include  the  typical 
course  of  the  disease;  the  appearance  of  the  wasting, 
first  in  the  small  muscles  of  the  hand;  the  gradual 
extension  of  the  atrophy  to  other  muscles  ;  the  absence  of 
sensory  disorders  and  the  immunity  of  the  sphincters  of 
the  bladder  and  the  rectum.  Progressive  muscular  atrophy 
is  excluded  in  diseases  where  the  wasting  is  only  a  sub- 
ordinate symptom.  It  is  distinguished  from  amyotrophic 
lateral  sclerosis  by  the  absence  of  spastic  symptoms  and 
the  normal  condition  of  the  reflexes.  The  differential 
diagnosis  from  the  myopathic  form  of  muscular  atrophy 
can  easily  be  inferred  from  the  description  of  the  latter 
disease  in  the  following  section. 

Prognosis.  Patients  may  survive  for  many  years  if  the 
atrophy  advances  slowly  and  makes  frequent  pauses. 
Recovery  even  under  the  most  favorable  conditions  is 
exceptional.  The  fatal  termination  is  hastened  when 
the  respiratory  and  masticatory  muscles  licome  affected. 


S  Y  S  T  E  M  I C   D  I S  E  A  S  E  S-  -S  PINAL   CORD.  IS', 

Treatment.  Electricity  appears  to  be  the  only  means  of 
exciting  some  favorable  influence  on  wasting  palsy. 
Duchenne  recommends  to  begin  the  treatment  at  once  with 
strong  faradic  currents  to  the  affected  muscles.  Galvan- 
ization of  the  spinal  cord  in  the  usual  method  should  be 
combined  with  it.  A  systematic  course  of  massage  may 
assist  in  arresting  the  advance  of  the  atrophy. 

PSEUDO-HYPERTROPHY    OF   MUSCLES. 

(Lypomatous-hypertropiiy  of  Muscles.) 
The  myopathic  class  of  muscular  atrophy  is  distin- 
guished from  the  spinal  form  of  the  disease  by  the  differ- 
ence that  the  anatomical  changes  in  the  former  develop 
in  the  muscles,  the  nervous  system  being  not  involved. 
Myopathic  atrophy  occurs  in  the  greater  number  of  cases 
in  the  young  members  of  the  same  family.  I  once  saw 
three  brothers  who  presented  the  typical  form  of  the  dis- 
ease. Boys  are  more  disposed  to  the  affection  than  girls. 
Nothing  is  noticed  until  the  patient  has  begun  to  walk. 
The  parents  cannot  understand  why  the  child  becomes 
unsteady  on  its  feet  and  constantly  stumbles  in  walking, 
although  its  limbs  are  straight  and  finely  developed.  The 
little  patient  makes  a  poor  effort  at  mounting  steps,  falls 
over  when  slightly  pushed  and  when  down  has  much 
trouble  to  get  up.  The  arms  and  hands  appear  perfectly 
normal,  but  the  attitude  in  standing  is  odd  and  the  walk 
is  a  mere  waddling.  In  fact  the  nature  of  the  child's 
disease  can  be  recognized  at  a  glance  by  observing  the 
position  of  the  body  and  the  character  of  the  gait.  The 
shoulders  and  the  upper  part  of  the  vertebral  column 
incline  backwards,  the  dorsal  curvature  is  deeply  arched, 


18:1  M  A  X  UAL   OF  N ER  V 0  U S   DISE A  S  ES  . 

the  abdomen  protrudes,  the  feet  are  kept  wide  apart 
and  the  patient  cannot  approximate  them  without  the 
risk  of  falling.  At  a  late  period  he  cannot  bring  the 
heels  to  the  ground  whilst  in  the  erect  position,  but  bal- 
ances his  body  on  the  toes  so  that  he  easily  loses  his 
equilibrium  when  slightly  pushed.  The  characteristic 
gait  resembles  the  movements  of  a  duck,  the  body  oscil- 
lates from  one  side  to  the  other.  Dr.  Ross  remarks: 
"  When  the  feet  are  kept  widely  apart  the  center  of 
gravity  must  be  carried  at  each  step  over  the  side  of  the 
active  leg  in  order  that  the  line  of  gravity  may  pass 
through  the  center  of  the  arch  of  the  foot  planted  on  the 
ground.  It  is  therefore  necessary  that  at  each  step  the 
body  should  be  inclined  well  over  the  side  of  the  active 
leg,  and  the  patient  aids  himself  in  maintaining  the 
center  of  gravity  vertically  above  the  ball  of  the  foot  on 
the  ground  by  moving  his  arms  about  like  a  rope 
dancer." 

The  series  of  movements  which  the  patient  adopts  in 
raising  himself  from  the  floor  when  there  is  nothing  near 
him  to  lay  hold  of  is  characteristic.  He  gets  on  all  fours, 
plants  his  feet  on  the  floor  and  props  himself  with  his 
extended  arms,  then  gradually  straightens  his  legs  so 
that  his  trunk  raises  and  assumes  an  inclined  position 
from  the  buttocks  downwards.  Having  gained  this  posi- 
tion he  next  grasps  one  knee  with  the  one  hand,  and 
while  the  other  hand  is  firmly  flxed  on  the  floor,  he 
stiffens  the  arm  to  support  himself,  and  then  quickly 
freeing  the  hand  he  grasps  with  it  the  other  knee,  and  in 
this  manner  the  trunk  is  brought  into  a  vertico-horizontal 
position  from  the  shoulder  downwards.  The  last  grand 
effort     to    gain    the    erect    position    he    accomplishes    by 


.S^  Y  S  T  E  M IC  DI S  E  A  S  E S  -S  P I X  A  L  C  O  R  D .  187 

thrusting  the  body  forwards  and  climbing  the  thighs 
with  his  hands. 

On  observing  for  the  first  time  the  precarious  attitude 
and  waddling  gait  of  the  patient,  attention  is  attracted 
by  the  remarkable  development  of  some  of  the  muscles. 
The  gastrocnimii  especially  have  gained  in  volume.  The 
gluteal  muscles  are  also  massive,  and  in  older  patients 
the  thigh  and  the  deltoid  are  sometimes  increased 
in  thickness.  "  This  pseudo-hypertrophy  "  is  caused  by 
an  increase  of  interstitial  fat.  The  real  cause  of  the 
feebleness  is  the  atrophy  of  numerous  muscles  w^hich 
strangely  contrast  with  the  excessive  volume  of  others. 
In  many  cases  the  thighs  are  thin  and  wasted,  while  the 
gastrocnimii  are  of  an  enormous  size.  The  muscles  of 
the  upper  extremities,  with  the  exception  of  the  deltoids, 
are  more  frequently  atrophied  than  enlarged.  Those  of 
the  shoulder  and  upper  part  of  the  body  are  occasionally 
attacked.  Usually  the  distribution  of  the  hypertrophy  is 
such  that  the  arms  and  upper  part  of  the  trunk  appear 
emaciated  in  comparison  with  the  development  of  the 
buttocks  and  the  calves. 

ErVs  juvenile  form  of  hereditary  muscular  atrophy  is 
also  a  disease  of  early  youth.  It  usually  attacks  the 
female  members  of  the  same  family.  The  atrophy  begins 
in  the  shoulders  and  arms  and  gradually  extends  to  the 
trunk  and  the  inferior  extremities.  In  all  cases  there  is 
a  remarkable  regularity  in  the  order  in  which  the  differ- 
ent muscles  are  attacked.  The  motor  disturbance  cor- 
responds to  the  extent  and  severity  of  the  atrophy.  There 
is  no  apparent  increase  in  the  volume  of  the  affected 
muscles.     The  disease    is  very  chronic,  but  sometimes  a 


18S  MA  N  UAL   0 F  N ER  VOUS   DISEA  S ES . 

sudden  fatal  termination  takes  place  from  asphyxia  in 
consequence  of  atrophy  of  the  diaphragm. 

Duchenne  reports  cases  of  atrophy  in  which  the  disease 
began  in  the  facial  muscles  and  then  extended  to  other 
muscles  of  the  body. 

In  all  the  forms  of  myopathic  atrophy  no  change 
occurs  in  the  nervous  system.  There  is  no  fibrillary 
twitching  of  the  muscle  and  the  reaction  of  degeneration 
is  not  manifest. 

Treatment  has  hitherto  proved  unavailing. 

BULBAR  PARALYSIS. 

(Glosso-labto-larynge.\l  Paralysis.) 

Etiology.  The  special  disease  of  the  medulla  oblongata 
which  Duchenne  originally  described  under  the  name  of 
glosso-labio-laryngeal  paralysis,  is  caused  by  a  degener- 
ative atrophy  of  the  nuclei  of  nerves  that  arise  on  the  floor 
of  the  fourth  ventricle.  To  the  group  of  symptoms 
resulting  from  this  lesion  that  chiefly  affects  speech, 
deglutition  and  respiration,  the  term  bulbar  paralysis  is 
now  generally  applied.  No  particular  exciting  cause  of. 
the  disease  is  known,  but  a  history  of  s^'philis  exists  in 
many  cases.  Men  between  the  ages  of  40  and  70  years 
are  chiefly  affected. 

Clinical  History.  Bulbar  paralysis  always  develops  very 
insidiously.  Slight  premonitory  symptoms,  such  as  pain 
in  the  back  and  front  of  the  neck,  precede  the  impedi- 
ment of  speech  that  first  attracts  the  attention  of  the 
patient.  He  experiences  difficulty  to  articulate  certain 
consonants,  usually  r,  s,  1,  k,  g  and  t.  Among  the  vowels 
he  pronounces  i  but  poorly.     This  defect  is  mainly  due  to 


SYS  TEMIC  DISEASESSPINAL   CORD.        189 

disturbed  innervation  of  the  tongue,  which  interferes 
with  the  mobility  of  this  organ.  As  the  disease  advances 
an  analogous  difficulty  occurs  in  chewing  and  swallowing 
food.  On  examination  the  tongue  is  found  atrophied,  it 
is  thin  and  flabby  and  grooves  form  upon  its  surface. 
At  a  later  period  the  tongue  can  no  longer  be  protruded. 
Morsels  of  food  remain  in  the  mouth,  as  they  cannot  be 
carried  back  by  the  tongue  into  the  pharynx. 

A  similar  debility  is  observed  to  affect  the  lips.  Read- 
ing aloud  becomes  quickly  tiresome.  The  acts  of  whistling, 
bloAving  and  sucking  are  but  imperfectly  performed,  and 
finally  puckering  of  the  mouth  is  impossible.  When  the 
paralysis  of  the  orbicularis  oris  increases  the  patient  is 
unable  to  pronounce  the  vowels  o  and  u,  and  he  finds 
it  difficult  to  articulate  the  consonants  p,  f  and  b. 

The  next  trouble  is  due  to  the  extension  of  the  paraly- 
sis to  the  pharynx  and  larynx.  Swallowing  is  interrupted 
and  the  voice  becomes  monotonous.  Liquid  food  regur- 
gitates through  the  nose  in  consequence  of  the  paralytic 
condition  of  the  soft  palate. 

Inability  to  modulate  the  voice  may  be  the  only  sign  of 
implication  of  the  laryngeal  muscles  for  a  long  time,  but 
more  serious  symptoms  develop  in  the  course  of  the  dis- 
ease. The  voice  becomes  extremly  feeble  and  hoarse, 
and  the  incomplete  closure  of  the  larynx  permits  the 
entrance  of  liquids  and  even  solid  food  into  the  air 
passages. 

A  very  characteristic  change  in  the  expression  of  the 
face  is  observed  if  in  addition  to  the  paralytic  condition 
of  the  lips  the  lower  facial  muscles  are  also  implicated. 
The  mouth  stands  wide  open;  the  lower  lip  hangs  down; 
the  naso-labial  fold  is  deepened,  while  the  muscles  of  the 


190  M A  XUAL   OF  N E R  V 0  US  1)1  S E A  S ES. 

upper  part  of  the  face  and  of  the  eyeballs  are  normal. 
There  is  a  constant  trickling  of  saliva  over  the  chin  so 
that  the  patient  is  seen  constantly  holding  a  pocket  hand- 
kerchief to  his  mouth.  Exceptionally  the  muscles  of 
mastication  are  involved,  which  in  addition  to  the  paral- 
ysis of  the  tongue  and  lips,  renders  chewing  extremely 
difficult.  Morsels  of  food  would  drop  out  if  the  patient 
did  not  prevent  it  by  pressing  the  palm  of  the  hand 
against  the  mouth. 

At  an  advanced  period  it  is  not  unusual  to  witness 
attacks  of  dyspnoea  and  fainting  fits.  These  symptoms 
indicate  implication  of  the  pneumogastric  nerve. 

When  the  disease  has  reached  its  height  another  symp- 
tom is  occasionally  added  to  the  catalogue  of  troubles, 
dependent  on  the  implication  of  the  spinal  accessory, 
and  causing  atrophy  of  the  muscles  of  the  neck.  The 
patient  in  consequence  experiences  much  difficulty  to 
keep  the  head  in  the  erect  position. 

Reflex  action  of  the  paralyzed  muscles  is  diminished, 
or  entirely  abolished.  Tickling  of  the  root  of  the  tongue 
does  not  cause  the  patient  to  gag. 

It  is  a  noteworthy  circumstance  that  all  the  symptoms 
enumerated  are  exclusively  motor.  The  cutaneous  sensi- 
bility and  the  senses  of  taste  and   smell  continue  intact. 

Course  and  Termiaatlon.  During  the  early  stage  of  the 
disease  there  is  nothing  in  the  outer  appearance  of  the 
patient  indicating  the  beginning  of  a  fatal  affection.  The 
paralysis  invades  in  the  order  that  has  been  stated,  first 
the  tongue,  then  the  lips,  then  the  soft  palate  and  lastly  the 
larynx.  The  general  health  of  the  patient  does  not  seem 
to  suffer  until  serious  difficulty  of  deglutition  develops. 
At  a  late  period   the  patient  presents  a  woeful   jncture  of 


S  YS  T  E  M  I  ('  1)  I S  E  A  S  ES—S  P  /  XA  L   C  O  R  T) .  101 

wretchedness.  Speech  is  gone,  the  desperate  attempts 
to  swallow  food  are  futile,  the  lips  are  thinned  to  trans- 
parency, the  mouth  constantly  gapes,  the  saliva  dribbles 
away,  and  amidst  all  this  the  intelligence  is  clear  and 
only  the  motions  of  the  eyes  convey  the  expression  of 
misery.     Death  may  be  postponed  for  three  or  five  years. 

Complications.  Bulbar  paralysis  stands  in  close  relation 
to  the  allied  affections  of  progressive  muscular  atrophy 
and  amyotrophic  lateral  sclerosis.  The  degenerative 
atrophy  of  the  nerve  nuclei  in  the  medulla  and  of  the 
corresponding  muscles  is  analagous  to  the  lesion  and 
its  consequences  that  characterize  the  latter  diseases. 
The  best  evidence  of  the  degenerative  process  in  the 
medulla  is  found  in  the  nucleus  of  the  hypoglossus  nerve, 
more  or  less  also  in  the  vagus  and  the  accessory  and  only 
sometimes  in  the  nucleus  of  the  facial  and  -of  the  glosso- 
pharyngeus.  A  similar  anatomical  change  is  observed 
in  the  nerves  that  start  from  these  nuclei. 

The  similarity  between  the  nature  of  the  pathologi- 
cal changes  in  bulbar  paralysis  and  progressive  mus- 
cular atrophy  is  complete.  In  both  of  these  diseases 
the  degenerative  atrophy  involves  the  motor  and  trophic 
nerve  tracts  and  the  corresponding  muscles.  The  lesion 
in  bulbar  paralysis  affects  the  nerve  nuclei  in  the 
medulla,  and  in  progressive  muscular  atrophy  the  lesion 
involves  the  ganglion  cells  of  the  anterior  gray  cornua. 
The  difference  implies  only  a  difference  in  the  localiza- 
tion of  an  identical  lesion.  It  is  now  easy  to  understand 
why  during  the  course  of  bulbar  paralysis  we  often  meet 
with  atrophy  of  the  extremities  and  conversely  that 
toward  the  late  period  of  progressive    muscular    atropliy 


li)3  MA  N  UA  L   OF  NER  VO  US  D IS EA  SES . 

symptoms  of  bulbar  paralysis  not  infrequently  make 
their  appearance. 

The  complication  of  amyotrophic  lateral  sclerosis  with 
bulbar  paralysis  has  also  been  met  with.  The  occur- 
rence of  spastic  symptoms  in  cases  of  this  kind  shows 
the  extension  of  the  primary  disease  in  the  medulla  to 
the  lateral  columns  of  the  spinal  cord. 

Diagaosis.  Symptoms  of  bulbar  paralysis  have  been 
observed  in  cases  which  turned  out  to  be  multiple  sclero- 
sis, obliteration  of  basal  arteries  or  tumor  of  the  medulla. 
In  all  such  cases,  however,  there  is  a  clinical  history 
which  markedly  differs  from  the  symptomatology  and 
course  of  a  typical  case  of  primarv  bulbar  paralysis.  It 
would  be  a  serious  mistake  to  confound  with  this  dis- 
ease the  aphonia,  the  choking  sensation  and  excessive 
salivation  suddenly  occurring  in  a  hysterical  woman. 

Prognosis.  Trousseau  makes  the  remark  in  reference  to 
the  prognosis  of  bulbar  paralysis  :  "  I  do  not  believe  that 
a  single  case  is  on  record  in  which  the  progress  of  this 
disease  has  been  arrested  for  a  single  minute." 

Treatment.  An  effort  should  at  least  be  made  to  check 
the  advance  of  the  disease.  Duchenne  and  Kussmaul 
observed  temporary  improvement  of  the  speech  and 
deglutition  from  faradisation  of  the  palate  and  tongue. 
Galvanization  may  possibly  be  of  some  service:  the  elec- 
trodes should  be  applied  to  the  mastoid  processes.  Diffi- 
culty of  swallowing  may  sometimes  be  relieved  by 
applying  the  kathode  to  the  side  of  the  larynx  and  the 
anode  to  the  nape  of  the  neck.  Excessive  salivation  is 
restrained  by  atropia. 


CHAPTER  XL 

DISEASP]S  OF  THE  MEMBRANES  OF  THE 
BRAIN. 

Diseases  of  the  cerebral  meninges  are  nearly  always 
of  a  secondary  nature,  and  more  or  less  involve  the  sub- 
stance of  the  brain.  Each  of  the  membranes  may  be 
separately  affected,  but  frequently  the  inflammatory  pro- 
cess commencing  in  the  dura  mater  extends  to  the  pia. 

INTERNAL  HEMORRHAGIC  PACCHYMENINGITIS. 

(H.T':matoma  of  the  Dura  Mater.) 

Etiology.  ILematoma  of  the  dura  mater  is  far  more 
frequently  met  with  on  the  dissecting-table  than  recog- 
nized during  the  life  of  the  patient.  It  is  sometimes 
found  in  connection  with  acute  febrile  diseases,  as  typhoid 
fever,  smallpox  pneumonia,  and  is  often  one  of  the  post_ 
mortem  appearances  in  the  general  paralysis  of  the 
insane,  senile  dementia  and  chronic  alcoholism,  l^sually 
the  disease  occurs  among  old  people  and  more  frequently 
in  men  than  in  women. 

Anatomical  Changes.  Hamiatoma  is  generally  considered  to 
originate  in  inflammation  of  the  internal  surface  of  the 
dura  mater,  which  leads  to  the  formation  of  a  new  mem- 
brane   and    extravasation    of   blood    within    its    meshes. 

In    old  cases  the  connective  tissue  of  which  the  mem- 

i;!  ( I'.i:; ) 


m  J/ ^4  X  UAL   0  F  y  EnVOUS  D I  SEAS  ES . 

brane  consists  is  much  thickened  and  filled  with  blood. 
The  new  growth  exerts  much  pressure  on  the  underlying 
part  of  the  brain.  Its  rupture  gives  rise  to  "  meningeal 
apoplexy."  The  usual  seat  of  the  hsematoma  is  the 
parietal  region. 

Clinical  History.  Symptoms  referable  to  hemorrhagic 
pacchymeningitis  are  not  characteristic  though  they  are 
sometimes  very  serious.  The  difficulty  of  diagnosis  is 
due  to  the  variable  location,  size  and  recurrence  of  the 
hemorrhage.  The  disease  gives  rise  to  headache, 
vertigo,  a  slow  pulse,  vomiting  and  stupor:  some- 
times hemiparesis  or  twitching  of  muscles  of  one  side 
of  the  body  is  a  conspicuous  S3'mptom,  or  only  on^ 
extremity  is  paralyzed  and  affected  with  convulsive 
movements.  The  paralysis,  if  the  hemorrhage  is  copious, 
may  become  bilateral.  Aphasia  occurs  in  some  cases. 
The  disease  may  begin  abruptly  like  an  apoplectic 
attack.  Drowsiness  is  often  a  prominent  symptom  in 
old  people,  and  when  conjoined  with  contracted  or  dilated 
pupils  the  possible  existence  of  a  ha?matoma  is  indicated. 

The  course  of  the  disease  is  very  variable.  In  many 
cases  improvement  takes  place;  the  paralysis  and  the 
other  symptoms  may  even  entirely  disappear,  but  only  to 
return  at  irregular  intervals  on  the  recurrence  of  the 
effusion.  Death  from  coma  suddenly  ensues  in  aggra- 
vated cases. 

Diagnosis  is  impossible  when  haematoma  occurs  as  a 
complication  in  affections  distinguished  by  other  promi- 
nent symptoms.  The  variable  clinical  features  the 
disease  assumes  must  at  any  rate  embarrass  its  recogni- 
tion. The  following  diagnostic  points  are  to  be  considered  : 


DISEASES   OF  MEMBRANES  OF  BBAIX.       19o 

Chronic  cerebral  disease,  alcoholism,  sudden  onset  of 
severe  cerebral  symptoms,  their  improvement  and  recur- 
rence, unilateral  spasms,  hemiplegia  or  monoplegia. 

Treatment.  It  is  impracticable  to  recommend  any 
special  line  of  treatment  in  a  disease  of  this  kind.  The 
apoplectiform  attacks  would  call  for  a  cooling  treatment 
and  derivatives,  and  paralysis  for  the  electric  treatment, 
etc. 

DISEASES    OF    THE    PIA    MATER. 

The  varieties  of  cerebral  meningitis  are  distinguished 
partly  by  their  etiology  and  partly  by  the  particular  seat 
of  the  inflammation.  The  pia  mater  is  chiefly  affected. 
We  distinguish  : 

1.  Tubercular  meningitis. 

2.  Meningitis  of  the  convexity. 

o.  Epidemic  cerebro-spinal  meningitis.  This  being 
an  acute  infectious  disease  it  cannot  be  properly  classed 
among  nervous  diseases. 


TUBERCULAR  MENINGITIS. 

(Acute  Hydrocephalus.) 

Etiology.  Tubercular  meningitis  is  generally  believed 
to  be  a  secondary  affection,  but  the  focus  of  infection 
in  remote  parts  of  the  body  cannot  always  be  found 
at  the  autopsy.  In  the  larger  number  of  cases  the  men- 
ingeal disease  in  adults  takes  place  in  the  course  of  pul- 
monary tuberculosis.  The  influence  of  age  is  marked. 
Tubercular   meningitis  most  frequently  affects  children. 


J   /  N  UA  L   O  F  XER  VOUS  Dl  S  EA  S  ES . 

AnatomiCil  Changes.  Miliary  tubercles  develop  in  greatest 
abundance  in  the  pia  mater  at  the  base  of  the  brain, 
hence  the  disease  is  often  characterized  as  "  basilar  men- 
ingitis." The  greater  number  of  tubercles  are  found 
along  the  course  of  the  large  blocd-vessels  and  furrows 
between  the  convolutions.  They  can  easily  be  detected  on 
stripping  the  hypersemic  membrane  from  the  brain.  The 
inflammatory  exudation  chiefly  consists  of  a  sero-fibrinous 
effusion,  which  is  sometimes  cloudy  from  the  presence  of 
a  scant  amount  of  pus.  Hemorrhagic  spots  are  frequently 
found  in  the  inflamed  pia.  Often  the  brain  substance 
is  also  involved  and  shows  deposit  of  tubercles  and 
capillary  haemorrhage.  Flattening  of  the  convolutions 
is  seen  when  the  exudation  is  large.  A  copious  eff"u- 
sion,  more  or  less  of  a  sero-purulent  appearance,  is 
usually  found  in  the  ventricles,  hence  the  disease  was 
formerly  termed  "acute  hydrocephalus."  The  pia  mater 
of  the  spinal  cord  is  often  conjointly  affected.  This 
membrane  being  inflamed  and  sometimes  studded  with 
tubercles  explains  the  combination  of  spinal  and  cerebral 
symptoms. 

Clinical  History.  It  is  convenient  for  description  tu  divide 
the  clinical  history  of  the  disease  into  three  stages.  The 
first  stage  includes  the  prodroma  due  to  cerebral  irrita- 
tion. The  second  stage  marks  the  .complete  development 
of  the  disease,  and  the  third  stage  is  the  stage  of  collapse 
corresponding  to  grave  impairment  of  important  nerve 
centers.  But  the  sudden  or  slow  development  of  the 
inflammatory  exudation,  the  variable  extent  and  severity 
of  the  cerebral  implication,  and  the  degree  of  compression 
exerted  by  the  eflfusion    constitute   factors   that   greatly 


DISK  A  SES  0  F  MEMBRA  NES  O  F  BRAIN.        197 

modify  the  symptomatology  and  course  of  the  disease  in 
individual  cases. 

The  onset  of  tubercular  meningitis  is  occasionally 
tumultuous.  In  topers  the  disease  not  seldom  begins  as  a 
delirium  tremens.  (Generally,  however,  the  disease  is 
preceded  for  a  longer  or  shorter  period  by  a  precur- 
sory stage.  For  a  week  or  two  patients  complain  of 
headache,  aversion  to  food,  constipation,  sleeplessness 
and  a  feeling  of  general  illness.  Vomiting  is  often  a  con- 
spicuous initial  symptom.  Tliis  condition  grows  worse, 
the  headache  increases,  delirium  comes  on,  and  soon  the 
marked  signs  of  a  formidable  brain  trouble  make  their 
appearance. 

In  children,  who  are  more  frequently  the  victims  of 
tubercular  meningitis  than  adults,  the  invasion  presents 
some  peculiarities.  It  often  appears  as  if  a  previous 
attack  of  measles,  hooping  cough,  or  other  affections  to 
which  children  are  prone,  had  hastened  into  activity  the 
dormant  process  of  tuberculosis.  But  apparently  healthy 
children  are  often  unexpectedly  taken  with  the  disease. 
There  are  families  who  lose  their  little  ones,  after  they 
have  arrived  at  a  certain  age,  from  "brain  fever."  An 
infant  refuses  the  breast,  sleep  is  disturbed,  the  tongue 
is  coated,  the  bowels  are  constipated,  and  towards  evening 
fever  appears.  The  little  patient  has  short  spells  of  cry- 
ing, is  exceedingly  restless  or  is  drowsy  and  often  vomits 
without  a  palpable  cause.  Usually  these  symptoms  are 
attributed  by  the  mother  or  nurse  to  difficult  dentition, 
indigestion,  worms,  or  disordered  bowels.  An  older  child 
has  headache,  refuses  food,  is  restless,  abandons  its  play- 
things, and  with  remarkable  frequency  complains  of  pain 
in  the  chest  and  abdomen.     In  very  young  children  it  is 


198  MA  X  UA  L   OF  NER  VO  US  D  IS EA  S  ES . 

not  iiniisiial  for  the  disease  to  set  in  suddenl}^  with  eleva- 
tion of  the  temperature  and  general  convulsions. 

The  second  stage  in  adults  may  begin  with  a  chill,  but 
the  most  prominent  and  constant  symptom,  when  the 
disease  is  completely  established,  is  violent  pain  in  the 
head.  It  persists,  with  short  intermissions,  as  long  as 
the  patient  is  at  all  conscious.  He  breaks  out  in  loud 
complaint  of  its  severity,  and  even  when  overcome  by 
the  advancing  drowsiness  the  contortions  of  the  face 
express  its  continuance.  (I  once  saw  a  little  girl  who  in 
this  stage  constantly  beat  her  forehead  with  the  fist.) 
Very  young  children  manifest  the  headache  by  the  repe- 
tition of  an  abrupt  shrill  cry  and  by  boring  the  head 
into  the  pillow  or  tossing  it  from  side  to  side. 

Delirium  is  an  early  symptom  iu  adult  patients.  They 
sing,  shout  or  whistle,  throw  off  the  bed  covering  and 
make  attempts  to  escape  from  the  room.  Sometimes  the 
delirium  is  low  and  less  noisy,  the  muttering  being  unin- 
telligible and  the  patient  picks  the  bedclothes. 

The  most  conspicuous  motor  symptoms  are  stiffness  of 
the  neck  and  retraction  of  the  head  due  to  implication  of 
the  upper  region  of  tlie  spinal  cord.  Various  symptoms 
showing  irritation  of  cranial  nerves  at  the  base  of  the 
brain  make  their  appearance.  There  is  twitching  of  the 
facial  muscles,  strabismus,  rolling  of  the  eyeballs  and 
later  ptosis  and  partial  facial  paralysis.  The  pupils  show 
much  irregularity,  they  may  be  unequal,  contracted  or 
dilated.  Usually  they  are  sluggish  and  finally  do  not 
respond  to  light.  Spasmodic  movements  of  the  limbs  are 
occasionally  observed,  but  more  frequently  a  rigid  condi- 
tion of  the  inferior  extremities  exists.  In  children  a 
boat-shaped     appearance    of    the    al)d()minal    walls    is 


DISEASES  OF  MEMBRANES  OF  BRAIN.       J99 

observed  toward  the  close  of  the  second  stage.  If  the 
patient  does  not  fall  early  into  a  state  of  unconsciousness 
there  is  generally  well  marked  hyper?esthesia  and  intol- 
erance of  light  and  sound. 

The  temperature  varies.  It  rarely  rises  above  103°, 
but  at  times  there  is  an  elevation  reaching  105°  to  106°, 
or  the  temperature  may  suddenly  become  subnormal. 

Remarkable  changes  of  the  pulse  are  noticed.  In  the 
early  stage  it  often  gets  as  low  as  60  or  50  beats  per 
minute,  and  later  it  becomes  exceedingly  rapid  and  feeble. 
The  "  tache  cerebral "  is  well  marked  in  small  children. 

The  respiration  is  often  sighing  and  nasal.  At  the 
early  stage  before  stupor  comes  on  the  breathing  is  acceler- 
ated, but  toward  the  end  it  is  hardly  perceptible. 

Constipation  of  the  bowels  persists  throughout  the  dis- 
ease. It  has  been  noticed  that  the  cough,  dyspnoea  and 
the  profuse  perspiration  in  phthisical  patients  cease  on 
the  development  of  meningitis,  but  the  marasmus  rapidly 
increases.  The  second  stage  of  the  disease  averages 
about  eight  days. 

The  third  or  final  stage  shows  the  signs  of  speedy  dis- 
solution. Swallowing  of  food  is  now  impossible.  The 
breathing  is  irregular  and  occasionally  assumes  the 
character  of  the  "  Cheyne  Stokes  respiration."  The  pulse 
can  hardly  be  counted,  the  extremities  are  cold,  and  the 
coma  is  profound.  In  children  the  fontanels  are  sunken 
and  often  death  is  ushered  in  by  general  convulsions  and 
paralysis.  Cases  of  recovery  from  tubercular  meningitis 
are  reported,  but  it  has  been  asked — how  about  the  diag- 
nosis ? 

Diagnosis.  There  are  few  diseases  of  infancy  that  offer 
greater  difficulties  to  diagnosis  than  the  prodromic  period 


wo  MA  N  UA  L   O  F  NER  VOUS  DISK  A  S  ES . 

of  tubercular  meningitis.  A  decisive  judgment  in  regard 
to  the  nature  of  the  symptoms  will  often  be  held  in  sus- 
pense until  positive  evidences  of  cerebral  trouble  appear. 
It  is  advisable  when  diagnosis  is  doubtful  not  to  disregard 
the  symptoms  of  incipient  pulmonary  tuberculosis  and 
to  examine  the  chest.  Scrofula  and  diseased  joints  are 
of  similar  import.  Suspicion  should  always  be  awakened 
if  a  child  begins  to  vomit  without  an  assignable  cause 
and  shows  great  irregularity  of  the  pulse.  If  the  invasive 
stage  of  tubercular  meningitis  in  adults  is  very  protracted 
and  accompanied  by  high  fever  it  may  suggest  the  devel- 
opment of  typhoid  fever.  Here  again,  a  cautious  opinion 
must  be  formed  until  the  disease  declares  itself.  The 
•ophthalmoscope  may  come  to  the  assistance  of  diagnosis 
if  tubercles  are  found  in  the  choroid.  The  differential 
•diagnosis  between  the  tubercular  and  simple  variety  of 
meningitis  chiefly  rests  on  the  question  of  etiology. 

It  is  sometimes  surprising  to  find  at  the  autopsy  ver\^ 
insignificant  changes,  that  seem  insufficient  to  account 
for  the  gravity  of  the  symptoms. 

Treatment.  An  infant  should  be  provided  with  a  healthy 
wet  nurse  when  tuberculosis  is  hereditary  on  the  mother's 
side.  Superabundance  of  clothing  and  a  hot  sleeping- 
room  are  rather  injurious  to  children  disjDOsed  to  brain 
trouble.  Tepid  bathing  and  friction  of  the  skin  should 
be  recommended,  and,  in  fact,  all  the  well-known  prophy- 
lactic measures. 

Energetic  treatment  in  tubercular  meningitis  is  of 
doubtful  benefit,  but  cold  applications  to  the  head  are 
very  serviceable  when  steadily  kept  up.  Purgatives  are 
indicated  at  the  early  stage.  Calomel  is  best  adapted  for 
children.     Iodide  of  potassium  deserves  a   trial.     These 


1) ISEA  S E S  0  F  M E M B  R  A  N E S   0  F  B  R  A  IN.        201 

little  patients  can  easily  tolerate  from  two  to  three  grain 
doses.  Warm  baths  give  temporary  relief  to  the  cere- 
bral excitement,  but  small  doses  of  Dover's  powder  or  a 
few  drops  of  a  morphia3  solution  should  not  be  withheld. 
Children  under  two  years  of  age  should  never  be  blistered. 
In  the  stage  of  collapse  stimulants  are  indicated,  but  they 
are  of  little  avail. 

MENINGITIS  OF  THE  CONVEXITY. 

Etiology,  Simple  meningitis  of  the  convexity  is  very 
rarely  an  idiopathic  disease.  It  is  probable  that 
sporadic  cases  may  be  examples  of  that  variety  of  the 
disease  which  is  known  as  the  epidemic  cerebro-spinal 
meningitis.  In  fact  simple  meningitis  is  so  frequently 
found  to  be  a  secondary  affection  that  many  observers 
doubt  its  occurrence  as  a  primary  inflammation.  In  place 
of  making  the  divisions  of  "traumatic  meningitis," 
"  metastatic  meningitis,"  etc.,  an  enumeration  of  the 
remote  causes  that  give  rise  to  purulent  inflammation  of 
the  cerebral  membranes  will  answer  every  practical  pur- 
pose. 

Disease  of  the  middle  ear  is  a  very  frequent  cause  of 
secondary  purulent  meningitis.  In  caries  of  the  petrous 
portion  of  the  temporal  bone,  which  is  usually  due  to 
otitis  media,  the  extension  of  the  disease  into  the  cranial 
cavity  is  easily  accounted  for.  Irruption  into  the  interior 
of  the  skull  may  take  place,  or  the  inflammation  proceeds 
from  the  mastoid  cells,  or  it  creeps  along  the  sheath  of 
the  nerves.  Suppurative  phlebetis  of  a  venous  sinus 
may  ensue  when  the  dura  mater  is  implicated.  Persons 
with  running  ears  are  in  constant  danger  of  such  a  com- 
plication.   The  meningitis  occurring  in  cases  of  this  kind 


W2  MAXUAL   OF  NERVOUS  DISEASES. 

begins  suddenly  and  with  violent  symptoms.  Disease  of 
the  upper  portion  of  the  nasal  cavity  may  possibly  also 
develop  meningitis. 

Injury  to  the  skull  is  one  of  the  most  frequent  causes 
of  purulent  meningitis,  and  calls  for  surgical  treatment. 
The  bursting  of  an  intracranial  abscess  invariably  develops 
meningitis.  All  other  cases  of  cerebral  meningitis  which 
are  not  traceable  to  a  direct  or  palpable  cause  are  proba- 
bly due  to  the  transmission  of  an  infectious  agent  from  a 
remote  organ.  "Metastatic  meningitis"  sometimes  devel- 
ops in  the  course  of  pneumonia,  t\"phoid  fever,  erysipelas, 
articular  rheimiatism,  empysemia,  and  very  rarely  in 
pyaemia. 

The  anatomical  changes  in  secondary  meningitis  are  as 
a  general  rule  limited  to  the  convexity  of  the  brain.  The 
pia  mater  is  injected  and  infiltrated  with  pus.  Thick 
greenish-yellow  pus  is  often  found  in  the  subarachnoid 
spaces  and  along  the  course  of  the  meningeal  blood-ves- 
sels. The  arachnoid  presents  in  places  an  opaque 
appearance.  Spots  of  softening  are  often  observed  in  the 
substance  of  the  brain  where  the  pia  is  adherent  to  the 
cortex. 

Clinical  History.  Tt  so  often  happens  that  the  symptoms 
of  secondary  meningitis  are  mixed  up  with  tliose  of  the 
primary  affection  that  the  latter  attracts  the  first  atten- 
tion. In  traumatic  meningitis  the  symptoms  of  compres- 
sion predominate.  The  base  of  the  brain  is  involved,  as 
Hutchinson  has  pointed  out  in  cases  where  hemiplegia 
exists.  In  a  case  of  meningitis  of  the  convexity,  which 
appears  to  be  primary  the  symptoms  resemble  in  nearly 
everv  feature  those  of  the  tubercular  varietv. 


D  IS  EA  SES  OF  MEMB  R  A  NES  OF  BRAIN.        203 

A  precursory  stage  in  meningitis  of  the  convexity  is 
either  not  well  marked  or  entirely  absent.  There  may 
be  an  initial  chill,  but  usually  the  invasion  of  the  disease 
is  announced  by  violent  headache  and  febrile  excitement. 
The  pain  in  the  head  is  intense  and  dominates  the  atten- 
tion of  the  patient.  It  may  be  limited  to  a  fixed  spot  or 
be  diffused  over  the  whole  head.  There  is  often  consid- 
erable elevation  of  the  temperature,  but  it  is  generally 
varying.  The  patient  is  restless  and  irritable,  he  shuns 
the  light  and  is  annoyed  by  loud  sounds;  the  eyes  glisten; 
the  pupils  in  the  beginning  are  usually  contracted;  a 
circumscribed  flush  is  seen  in  the  face;  the  respiratiori 
is  somewhat  hurried  or  irregular;  speech  is  slow  and  at 
times  incoherent;  an  active  or  low  delirium  soon  sets  in; 
stupor  develops,  and  finally  a  deep  coma  is  established. 
Stiffness  of  the  neck  and  retraction  of  the  head  may 
supervene. 

Remarkable  variations  of  the  pulse  are  observed.  It 
may  be  excedingly  rapid  at  times,  but  quite  as  often  it  is 
very  slow,  irregular  and  intermittent. 

Symptoms  corresponding  with  implication  of  cranial 
nerves  as  in  tubercular  meningitis  are  noticed  in  individ- 
ual cases,  especially  disturbances  of  the  motor  oculi. 
Twitching  of  muscles  and  paralysis  of  the  hemiplegic 
type  may  likewise  occur. 

The  course  of  the  disease  is  often  rapid,  death  taking 
place  in  two  or  three  days,  either  preceded  by  coma  or 
convulsions.  Sometimes  the  fatal  termination  is  post- 
poned beyond  a  week.     Recovery  is  exceptional. 

Cerebral  meningitis  occurring  in  persons  of  an  advanced 
age  presents  certain  peculiarities.  The  symptoms 
develop   insidiously;    there   is    but   slight    headache,  the 


m  J/^  -V UAL  0 F  KEB  VOUS  D ISEA  S  ES . 

fever  is  moderate,  delirium  comes  early  and  is  often 
quickly  succeeded  by  coma.  In  other  cases  there  is 
merely  mental  confusion,  a  vacant  expression  of  the 
face,  tremor  and  rapid  sinking  of  the  vital  powers. 

The  very  dangerous  cephalic  symptoms  sometimes  met 
with  in  acute  articular  rheumatism  resemble  those  of 
meningitis,  though  the  post  mortem  appearances  are  not 
decisive. 

Diagnosis.  It  is  a  ditficult  point  of  differential  diagnosis 
to  discriminate  between  meningitis  and  encephalitis. 
Practically  it  is  of  no  moment,  for  the  brain  is  more  or 
less  involved  in  all  cases  of  cerebral  meningitis.  Diag- 
nosis may  be  embarrassed  when  cej^halic  symptoms  in 
severe  cases  of  typhoid  fever,  pneumonia  or  general 
tuberculosis  are  exceptionally  prominent.  Careful  anal- 
ysis of  the  symptoms  will  usually  overcome  the  diffi- 
culty. Those  indicating  the  existence  of  meningitis 
include  violent  and  persistent  headache,  the  early  onset 
of  cerebral  excitement,  delirium,  stupor,  rigidity  of  the 
neck,  ocular  paralysis  and  the  gravity  which  the  disease 
quickly  assumes. 

Treatment.  There  is  a  great  temptation  in  encountering 
the  grave  symptoms  that  characterize  all  forms  of  cere- 
bral meningitis  to  adopt  an  energetic  plan  of  treatment. 
Formerly  it  was  the  rule  to  practice  venesection,  now  we 
are  content  to  appl}^  leeches  to  the  head.  More  reliance 
is  to  be  placed  on  the  application  of  cold  to  the  head. 
The  ice  helmet  or  irrigator  answers  this  purpose  far  better 
than  bladders  filled  with  ice.  In  addition  a  woolen 
cloth  wrung  out  in  warm  water  may  be  wrapped  around 
the  lower  limbs.     In  desperate  cases  it  is  recommended 


DISEASE  S  0  F  M  E  M  B  R .  I  X  ES  OF  BRA  I X .        Mo 

to  shave  the  scalp  and  to  raise  a  blister.  I  have  never 
seen  a  good  effect  from  it.  Iodide  of  potassium  in  fre- 
quent doses  is  indicated.  The  bowels  are  best  kept 
open  by  small  doses  of  calomel.  Morphia  injections  may 
become  necessary  to  allay  extreme  cerebral  excitement. 


CHAPTER  XII. 

LOCALIZATIOX  OF  CEREBRAL   DISEASES. 

The  diseases  which  chiefly  produce  focal  lesions  of  the 
brain  are  cerebral  hemorrhage,  softening  from  occlusion 
of  cerebral  arteries  and  cerebral  tumor.  The  symptoms 
to  which  these  diseases  give  rise  do  not  depend  on  the 
nature  of  the  pathological  change,  but  on  its  locality.  It 
makes  no  difference  what  the  character  of  the  lesion  may 
be,  which  for  example  destroys  any  part  of  the  pyramidal 
tract  in  the  brain,  it  is  always  followed  by  hemiplegia. 
In  an  analogous  way,  whatever  may  be  the  nature  of 
irritation  or  interruption  that  implicates  an  excitable 
area  of  the  cortex,  it  will  either  cause  a  monospasm  or 
monoplegia.  Aphasia  develops  when  a  part  of  the  speech 
mechanism  in  the  brain  is  involved  by  any  kind  of  lesion. 
The  following  brief  summary  of  the  pathological  diagnosis 
of  cerebral  diseases  includes  the  results  of  clinical  obser- 
vations and  experiment. 

Lesion  of  the  central  convolutions,  produces  hemiplegia 
of  the  opposite  side  of  the  body.  Implication  of  separate 
parts  of  this  region  gives  rise  to  corresponding  forms  of 
partial  hemiplegia.  We  are  thus  enabled  to  localize  dis- 
ease in  this  region.  It  will  be  recollected,  that  the  center 
of  movement  for  the  leg  is  in  the  upper  part  of  the 
central  convolution  or  in  the  paracentral  lobule  ;  for  the 
movements  of  the  arm  in  the  middle  third  of  the  anterior 
(  -joc. ) 


LOCALIZA  TIO  N—CEREB  RAL  DIS  EA  S  ES.       207 

ascending  convolutions  ;  for  the  movements  of  the  facial 
muscles  in  the  lower  third  of  these  convolutions  and  that 
for  the  tongue  somewhat  lower.  Disease  affecting  any  of 
these  parts  causes  either  isolated  monoplegia  or  a  com- 
bined form  of  monoplegia  in  conformity  with  the  posi- 
tion and  extent  of  the  lesion.  The  commonest  form  of 
such  a  combined  paralysis  is  that  of  the  arm  and  face. 
The  simultaneous  paralysis  of  the  leg  and  face  has  never 
been  seen,  for  the  reason  that  the  intermediate  arm  cen- 
ter would  not  escape  in  a  lesion  affecting  the  other  two 
centers. 

If  a  cortical  lesion  of  these  centers  causes  irritation, 
then  we  have  either  "  monospasm"  (muscular  twitching, 
tremor),  or  simultaneous  spasm  of  the  muscles  of  the  face, 
arm  and  leg.  It  has  been  demonstrated  that  these  motor 
centers  are  involved  in  cases  of  unilateral  epileptic  convul- 
sions associated  with  hemiplegia  of  the  same  parts. 

Disease  of  the  second  and  third  frontal  convolutions  cause 
no  marked  disturbance  of  function,  but  mental  symptoms 
develop  if  these  regions  in  both  hemispheres  are  affected. 
Lesion  of  the  third  or  inferior  frontal  convolution  of  the 
left  hemisphere  gives  rise  to  the  interesting  phenomena 
of  aphasia. 

Parietal  convolutions.  It  is  uncertain  whether  cortical 
lesion  of  the  parietal  lobe,  exclusive  of  the  ascending 
parietal  convolution,  gives  rise  to  any  symptom.  Impair- 
ment of  the  cutaneous  and  muscular  sense  has  been 
observed  in  a  few  cases. 

Temporal  lobe.  There  exists  satisfactory  evidence,  tliat 
extensive  disease  of  the  superior  convolution  of  the  tem- 
peral  lobe  gives  rise  to  the  aphasic  symptom  of  "  word 
deafness." 


208  MA  X  UAL   OF  N  E  R  VO  US  D  I  SEA  SES . 

Occipital  lohc.  Experiments  and  pathological  invest!" 
gations  leave  no  room  for  doubt  that  the  occipital  lobe 
contains  a  center  of  vision.  Destruction  of  the  occipital 
lobe  does  not  cause  paralysis. 

Centrum  ovale.  Lesion  of  the  centrum  ovale  may 
exist  without  causing  any  symptoms.  This  immunity  is 
due  to  the  circumstance  that  a  sufficient  number  of  nerve 
fibres  remain  intact  to  conduct  innervation.  If  paralysis 
occurs,  it  cannot  be  distinguished  from  ordinary  hemi- 
plegia. 

Island  of  Reil.  The  island  is  not  infrequently  involved 
in  extensive  disorganization  of  neighboring  parts. 
Aphasia  has  been  observed  in  exclusive  lesion  of  the 
island. 

Thalamii.^  Opticus.  Although  the  thalamus  is  very  fre- 
quently involved  in  cerebral  hemorrhage  and  occlusion 
of  cerebral  arteries  there  is  considerable  discrepancy 
among  observers  in  regard  to  the  symptoms  peculiar  to 
lesion  of  this  basal  ganglia.  Cases  are  reported  in  which 
old  standing  lesions  of  this  ganglia  had  remained  entirely 
latent.  In  the  great  majority  of  instances  the  ordinary 
type  of  hemiplegia  existed  and  was  sometimes  accom- 
panied by  hemian?psthesia.  Hemiplegia  occurring  in 
lesion  of  the  thalamus  is  probably  due  to  a  co- existent 
lesion  of  the  internal  capsule  or  of  the  corpus  striatum. 
The  occasional  occurrence  of  hemian<Tsthesia  in  connec- 
tion with  a  lesion  of  the  thalamus,  may  be  due  to  the 
implication  of  the  posterior  inferior  portion  of  the  internal 
capsule  which  contains  sensory  paths.  Xothnagel,  in  an 
exhaustive  analysis  of  published  cases  of  lesion  of  the 
thalamus,  comes  to  the  conclusion,  that  a  focal  lesion  of 
this  basal  ganglia  never   gives  rise    to  motor  paralysis. 


LOCALIZATl  O  X—C  EREB  R  A  L   I  J 1  S  EASES.       209 

The  symptoms  most  frequently  observed  are  post-hemi- 
plegic  chorea,  athetosis  and  tremor  of  the  paralyzed 
limbs.  Visual  disturbances,  especially  hemianospia, 
have  also  been  observed.  There  exists  a  connection 
between  the  pulvinar  (posterior  extremity  of  the  thal- 
amus opticus)  and  the  optic  tract.  It  should  also  be 
mentioned  that  temporal  and  nasal  hemianopsia  are 
often  diagnostic  of  a  lesion  in  the  frontal  fossa,  impli- 
cating the  optic  tract. 

Corpus  Striatum.  Destruction  of  the  Corpus  Striatum 
from  hemorrhage  or  softening  gives  rise  to  the  most  com- 
mon form  of  hemiplegia.  The  exceeding  frequency  of 
lesion  of  this  central  ganglia  is  chiefly  due  to  its  vascular 
and  friable  texture.  The  caudate  and  lenticular  nucleus 
of  the  striated  body  has  been  divided  by  Duret  into  differ- 
ent vascular  districts,  which,  according  to  Charcot,  may 
be  separately  involved  and  thus  give  rise  to  modified  forms 
of  hemiplegia.  In  all  of  them  the  internal  capsule  is 
more  or  less  implicated.  The  lesion  in  the  ordinary  form 
of  hemiplegia  is  situated  in  the  central  portion  of  the  cor- 
pus striatum.  The  lesion  in  the  severe  form  of  hemiple- 
gia affects  the  region  of  the  corpus  striatum  where  the 
internal  capsule  runs  between  the  caudate  and  lenticular 
nuclei,  or  between  the  thalamus  opticus  and  the  lenticu- 
lar nuclei.  In  the  latter  region  the  lesion  may  cause 
either  a  permanent  hemianff'sthesia  alone,  or  the  combin- 
ation of  hemiplegia  and  hemianpesthesia. 

The  diagnosis  of  a  lesion  of  the  corpus  striatum  is 
probably  correct  in  the  large  majority  of  cases  of  hemi- 
plegia, when  the  paralysis  affects  the  arm,  leg  and  face 
with  temporary  paralysis  of  the  hypoglossus,  no  other 


:.'10  M  A  y  CAL   OF  X  ERVOUS   DfS  E  A  S  E  S . 

crarial  nerve  being  affected.  The  jDaralvsis  of  the  face 
and  tongue  which  usually  attends  hemiplegia  in  lesion 
of  the  corpus  striatum  shows  the  close  proximity  of  the 
central  paths  of  the  facial  and  hypolgossus  nerves  to 
the  motor  fibres  of  the  internal  capsule,  wdiich  are  dis- 
tributed to  the  extremities.  It  is->now  generally  conceded 
that  hemiplegia  in  lesion  of  the  corpus  striatum,  is  invari- 
ably dependent  on  implication  of  the  internal  capsule. 
Cases  are  reported  in  which  an  old  focal  lesion  existed  in 
the  strialed  body,  that  had  not  given  rise  to  hemiplegia. 
In  such  cases  the  internal  capsule  was  evidently  not 
involved. 

Disturbance  of  sensation  rarely  accom2:)anies  hemi- 
plegia in  disease  of  the  corpus  striatum,  but  the  following 
exceptional  forms  of  paralysis  have  been  observed  in 
lesionof  this  ganglia: 

1.  Hemianaesthesia  of  the  same  side  as  the  hemiplegia, 
but  disappearing  at  an  early  date.  The  sensory  paralysis 
in  such  a  case  is  only  an  indirect  symptom. 

2.  The  hemiaucTsthesia  like  the  hemiplegia  is  a  perma- 
nent symptom. 

3.  Hemian£esthesia  alone  permanent  or  complicated 
with  cross  paralysis  of  special  senses. 

The  anaesthesia  affects  the  same  side  as  the  hemiplegia 
when  these  forms  of  paralysis  co-exist.  The  cutaneous 
sensibiUty  in  such  cases  is  impaired  or  entirely  abolished 
on  the  affected  side  from  head  to  foot,  and  is  attended  by 
impairment  of  sensibility  of  the  corresponding  mucous 
membranes  and  of  the  muscular  sense.  The  most  prom- 
inent symptom  in  regard  to  the  implication  of  the  special 
senses  is  cross  amblyopia  or  amaurosis. 


LOCALIZA  TION—CEREBRA  L  DISEASES.       211 

Pathological  diagnosis  in  all  cases  of  destructive  disease 
of  the  corpus  striatum,  which  are  marked  by  the  typical 
form  of  hemiplegia  and  attended  by  disturbances  of  sen- 
sibility, locates  a  lesion  that  involves  the  region  of  the 
posterior  division  of  the  internal  capsule. 

Charcot  has  drawn  attention  to  the  appearance  of 
vaso-motor  symptoms  in  hemiplegia  due  to  disease  of 
the  corpus  striatum.  These  are  the  occurrence  of 
oedema  and  changes  of  temperature  in  the  ])aralyzed 
limbs,  besides  some  other  symptoms  relating  to  the  sym- 
pathetic nerve.  Although  the  intracerebral  path  of  this 
nerve  is  undetermined,  it  is  known  that  it  passes  the 
crura  cerebri  and  must  therefore  occupy  a  part  of  the 
internal  capsule. 

Post-hemiplegic  chorea  is  not  due  to  lesion  of  fibres  of 
the  internal  capsule,  as  it  was  formerly  supposed,  but  to 
a  lesion  involving  certain  fibres  that  come  from  the  thala- 
mus optici. 

Corpora  Quadrigemina.  These  basal  ganglia  are  sup- 
plied by  arterial  branches  which  are  also  distributed 
to  adjacent  parts  of  the  cerebrum.  This  accounts  for 
the  meagre  report  of  cases  of  hemorrhage  in  which 
this  lesion  was  solely  located  in  the  corpora  quadri- 
gemina. The  information  concerning  the  special  symp- 
toms manifested  in  lesion  of  these  bodies  is  gathered 
from  the  effects  of  tumors.  Apart  from  the  symptoms 
common  to  all  cerebral  tumors,  it  appears  that  lesion  of 
a  part  or  of  all  the  corpora  causes  visual  disturbances 
chiefly  affecting  branches  of  the  motor  oculi.  In 
another  class  of  cases  symptoms  of  incoordination  were 
prominent. 


202  MA  X  UAL  0  F  NER  VOUS   Dl  S  EA  S  ES . 

The  Cerebellum,  Hemorrhage  and  embolism  of  the  cere- 
beUum  are  of  very  rare  occurrence.  A  clinical  distinction 
between  cerebellar  and  cerebral  apoplexy  is  not  practic- 
able. The  extravasation  of  blood  into  the  cerebellum  is 
always  marked  by  violent  symptoms.  The  hemorrhage 
affecting  one  of  its  hemispheres  usually  bursts  into  the 
fourth  ventricle,  involving  the  medulla  and  the  pons. 
Histories  of  total  destruction  of  the  lateral  half  of  the 
cerebellum  from  softening  show  complete  latency,  but 
symptoms  of  much  significance  are  often  witnessed  from 
the  presence  of  tumor,  usually  tuberculous,  in  the  vermi- 
form process  and  the  crura  cerebelli.  The  characteristic 
symptoms  of  lesion  of  the  worm  include  a  reeling  sway- 
ing gait,  vertigo  and  vomiting.  Accessory  symptoms, 
such  as  amblyopia,  amaurosis,  epileptiform  convulsions 
and  severe  pain  in  the  head  are  incidental  to  all  cerebral 
tumors. 

Certain  remarkable  forced  movements  are  observed  in 
lesion  of  the  middle  peduncle  of  the  cerebellum  (ad  pon- 
tem).  These  phenomena  consist  of  lateral  deviation  of 
the  head  and  eyes  and  rotatory  movements  of  the  body. 
As  these  symptoms  have  not  been  observed  in  focal 
lesion  of  other  parts  of  the  brain,  they  may  be  considered 
diagnostic  of  disease  of  the  cerebellum. 

Pons  Varolii.  Hemorrhage  of  the  pons  is  of  rare 
occurrence  and  is  not  easily  distinguished  from  hemor- 
rhage of  other  parts  of  the  brain.  Speedy  death  is 
exceedingly  common  on  account  of  the  proximity  uf 
the  medulla  to  which  the  extravasation  usually  spreads. 
Marked  stertor  and  irregularity  of  the  heart's  action 
are  witnessed  from  the  outset.  Deviation  of  the  eyes 
and    rotation    of    the    head,    which    are    always    grave 


LOCAL//.  A  no  y~  C  E  R  E  B  It  AL  DI S  E  A  S  ES.        213 

syiiiptoins  in  cerebral  apoplexy,  also  occur  in  hemor- 
rliage  of  the  pons.  The  pupils  are  sometimes  so 
extremely  contracted,  that  in  connection  with  the 
coma,  opium  poisoning  is  simulated.  Symptoms  of 
motor  irritation  quite  often  develop  in  pons  lesions. 
They  consist  of  partial  spasm  or  epileptiform  convulsions. 
In  large  hemorrhage  of  the  pons  there  is  usually  a  general 
relaxation  of  the  whole  muscular  system.  The  most 
reliable  evidence  of  the  existence  of  a  pons  lesion,  whether 
it  be  a  hemorrhage,  embolism  or  tumor,  is  a  peculiar 
form  of  paralysis  (alternate  paralysis).  It  differs  from 
typical  cerebral  hemiplegia  in  this,  that  the  paralysis 
affects  the  upper  and  lovyer  extremities  of  one  side  of  the 
body,  opposite  to  that  of  the  lesion  and  the  face  on  the 
same  side  as  the  lesion.  In  this  form  of  paralysis  there 
is  sometimes  implication  of  the  hypoglossus.  The  abdu- 
cens  and  the  trigeminus  are  less  frequently  involved. 
If  ordinary  hemiplegia  exists  as  is  seen  in  lesion  of  the 
basal  ganglion,  the  diagnosis  of  a  pons  affection  is  impos- 
sible. 

Crura  Cerebri.  In  hemorrhage  or  embolism  of  either 
the  thalamus  opticus  or  the  inferior  extremity  of  the 
corpus  striatum,  one  of  the  crura  is  sometimes  indirectly 
involved.  This  complication  arises  from  the  circum- 
stance that  these  parts  are  supplied  by  branches  of 
the  posterior  cerebral  artery.  But  in  a  focal  lesion 
confined  to  one  of  the  cerebral  peduncles  a  very  char- 
acteristic form  of  paralysis  is  seen.  The  hemiplegia 
affects  the  extremities  on  the  side  opposite  to  the  lesion, 
and  the  motor  oculi  of  the  same  side  as  the  lesion.  All 
the  ocular  muscles  to  which  branches  of  this  nerve  are 
distributed  are  paralyzed,  and,  in  consequence,  divergent 


214  MA  X  UA  L   0  F  XER  VO  US   DISEA  S ES . 

strabismus  and  diplopia  develop.  The  facial  and  hypo- 
glossal are  usnalh^  involved  on  the  same  side  as  the 
extremities  are.  Anaesthesia  is  also  noticed,  always  on 
the  side  opposite  to  the  lesion,  but  it  is  a  subordinate 
symptom.  If  a  lesion  of  the  crura  does  not  produce  the 
alternate  form  of  paralysis,  as  stated,  but  only  the  usual 
form  of  a  cross  paralysis,  it  cannot  be  diagnosed. 

Medulla  Oblongata.  The  causes  that  give  rise  to  focal 
lesions  in  different  parts  of  the  brain  seldom  affect  the 
medulla  oblongata.  Hemorrhage  of  this  organ,  which  is 
extremely  rare,  usually  causes  instantaneous  death.  If 
the  patient  survives  the  onset  symptoms  arise  that  can- 
not be  discriminated  from  those  presented  by  ventric- 
ular hemorrhage  or  a  large  clot  in  the  pons.  Cases  of 
inflammatory  softening  of  the  medulla  are  described 
under  the  head  of  "  apoplectic "  or  "  acute  bulbar 
paralysis,"  which  is  marked  by  a  group  of  symptoms 
greatly  resembling  those  of  the  chronic  degenerative 
disease  of  the  medulla  known  as  "  labio-glosso-laryngeal 
paralysis."  The  latter  is  an  entirely  different  affection. 
The  most  prominent  symptoms  of  the  former  include 
cross  hemiplegia  or  paraplegia  and  very  grave  disturb- 
ance of  the  respiration  and  circulation. 


APHASIA. 

Anomaly  of  speech  was  the  first  symptom  that  led  the 
way  in  the  search  for  the  "  localization  of  the  functions  of 
the  brain."  Although  it  would  be  misleading  to  speak  of 
a  '^center  of  speech,"  for  the  faculty  of  language  requires 
the  action  of  a  complicated  mechanism,  yet  pathological 
investigations  and  experiment  leave  no  room  for  doubt 


LOCAL  IZA  TIO  N-CEREBRA  L  D ISEA  SES.       215 

tliat  definite  parts  of  the    cerebrum    stand   in  intimate 
relation  to  the  function  of  speech. 

Aphasic  disturbances  of  speech  are  manifested  in  many 
different  ways,  and  various  forms  of  the  disorder  are 
often  observed  in  the  same  individual.  In  complete  loss 
of  the  memory  of  language,  the  patient  may  know  very 
well  what  he  wishes  to  express,  and  correctly  answer 
questions  by  gesticulations,  but  the  words  have  escaped 
him.  He  may  understand  the  meaning  of  the  word  that 
is  spoken  to  him,  or  he  may  not.  He  may  repeat  a  word 
or  short  sentence  he  has  heard  spoken,  but  he  cannot  of 
himself  express  a  thought.  Sometimes  an  aphasic  patient 
uses  one  or  several  words,  whether  they  have  a  meaning  or 
none,  as  the  only  vehicle  of  his  thoughts.  I  once  attended 
a  hemiplegic  woman  who  made  invariable  use  of  the 
senseless  word  "ninny"  and  none  other,  whenever  she 
desired  to  ask  for  something  or  intended  to  answer  a 
question,  although  she  understood  spoken  and  written 
language.  Other  aphasics  command  a  limited  vocabu- 
lary, and  are  foiled  when  desiring  to  express  a  long  or 
complicated  sentence.  It  is  an  interesting  fact  that 
certain  aphasics  are  able  to  speak  with  great  facility 
under  the  momentary  influence  of  strong  emotional 
excitement.  Graves  reports  the  case  of  an  aphasic  patient 
who  only  knew  the  initial  letters  of  words  and  had 
to  consult  the  dictionary  for  the  rest.  Such  forms  of 
partial  aphasia  are  very  common.  An  aphasic  person 
may  forget  his  own  name  or  those  of  his  wife  and  chil- 
dren. In  all  these  instances  of  aphasia  the  fault  is 
on  the  intellectual  side.  Another  important  form  of 
aphasia  relates  to  the  fault  on  the  motor  side.    There  are 


216  MA  N  UAL   OF  NER  VO  US   D  I  SEA  SES . 

aphasic  patients  who  have  a  complete  knowledge  of 
words  that  correctly  express  their  ideas  and  perfectly 
understand  what  is  spoken  to  them,  but  they  have  lost  the 
capacity  for  the  movements  by  which  language  is  articu- 
lated, although  the  muscles  engaged  in  speech  are  sound 
and  not  paralyzed.  A  third  chief  variety  of  aphasia 
consists  in  the  use  of  wrong  words.  The  patient  is  not 
aware  of  this  defect,  and  Avill  often  show  his  vexation  at 
not  being  understood. 

The  question  arises,  what  part  of  the  brain  is  involved 
in  aphasia  ?  It  is  now  universally  believed,  on  the 
strength  of  reliable  statistics,  that  in  the  vast  majority  of 
cases  of  aphasia  the  lesion  is  located  in  the  left  hemis- 
phere. Of  260  cases  of  aphasia,  Seguin  found  the  lesion 
in  the  left  hemisphere  in  243;  in  the  right  in  17:  a 
proportion  of  14.3  to  1.  In  Lohmayer's  table,  out  of 
53  cases  of  aphasia  there  are  34  in  which  the  third  or 
inferior  frontal  convolution  of  the  left  hemisphere  was 
diseased.  This  is  the  convolution  in  which  Broca  lirst 
discovered  the  aphasic  lesion.  The  island  of  Reil  comes 
next  in  frequency  as  the  seat  of  the  lesion.  Other  por- 
tions of  the  left  hemisphere  which  are  less  often  involved 
are  the  superior  temporal  convolution  bordering  on  the 
fissure  of  Sylvius  and  the  corpus  striatum  of  the  left 
hemisphere. 

Kussmanl  classifies  aphasic  symptoms  under  the  fol- 
lowing heads: 

1.  Ataxic  (or  motor)  aphasia.  There  is  incapacity  of 
motor  innervation  of  words.  Patients  have  lost  the  power 
either  totally  or  partially  of  coordinating  the  move- 
ments for    articulate    speech.       They  fully    understand 


L  OCA  LIZA  TiO  N-CEREB  RAL  DIS  EA  S  ES.       217 

the  language  spoken  to  them.  The  gross  muscular  power 
of  the  organ  engaged  in  articulation  is  retained,  but  the 
ability  to  associate  the  movements  required  in  uttering 
words  is  lost. 

2.  Amnesic  aphasia.  (This  is  the  sensory  aphasia  of 
Wernike.)  There  is  incapacity  for  the  recollection  of 
words  as  aggregate  acoustic  sounds.  The  idea  is  pres- 
ent, but  the  word  is  wanting,  although  articulation  is  at 
the  service  of  the  word. 

3.  Word  dumbness^  or  the  inability  with  good  hearing 
and  sufficiently  preserved  intelligence  to  understand 
words.     This  defect  is  also  called  "word  deafness." 

4.  Paraphasia.  There  is  an  inability  to  properly  con- 
nect word  images  and  correspondin  g  conceptions.  Instead 
of  words  expressing  the  idea  intended  to  be  conveyed, 
they  are  misplaced,  or  confused  word  images  present 
themselves  to  the  aphasic. 

Aphasic  disturbances  in  individual  cases  may  range 
from  slight  defects  of  speech  to  its  entire  abolition.  In 
ataxic  or  motor  aphasia,  the  mental  images  of  words  are 
intact.  The  stock  of  auditory  representatives  of  words  is 
retained.  There  is  in  this  form  of  aphasia  no  actual  loss 
of  muscular  power  of  the  organ  of  speech,  but  the  revival 
of  the  motor  images  of  speech,  that  formerly  readily 
responded  with  corresponding  articulation  is  imperfect  or 
abolished.  The  patient  has  lost  the  gift  of  adequately 
adjusting  the  associated  movements  for  the  formation  of 
words.  Many  of  us  in  the  healthy  condition  have  often 
experienced  an  analagous  difficulty  in  states  of  mental 
excitement^to  find  words  to  express  our  thoughts,  which 
under    ordinarv    circumstances    would    flow    freely.     It 


S18  MA  X  UA  L   OF  XER  VO  US  DIS EA  SES . 

appears  as  if  the  resource  on  which  we  abvays  confi- 
dently rely  for  supplying  us  with  words  had  for  the 
moment  failed  us. 

Mental  images  of  words  in  amnesic  aphakia  cannot  be 
recalled,  or  only  to  a  partial  extent.  The  general  intelli- 
gence is  clear,  and  the  corresponding  function  for  the 
articulation  of  words  may  be  perfectly  intact,  but  lan- 
guage, either  vocal  or  written,  has  lost  its  meaning.  The 
conceptions  as  they  arise  in  consciousness  do  not  excite 
memory  of  the  corresponding  words,  or  the  words  that 
are  heard  fail  to  evoke  the  mental  images  they  represent. 
The  patient  hears  the  words,  he  is  not  deaf,  but  he  does 
not  understand  what  the  Avords  signify. 

Word  dumbness  often  occurs  as  the  only  indication  of 
aphasia.  A  patient  may  fail,  for  example,  to  recall  the 
name  of  his  father  or  his  own  child,  but  perfectly  under- 
stands who  is  meant  when  he  hears  the  name  spoken. 

In  paraphasia  there  is  an  interruption  of  the  associa- 
tion of  an  idea  and  its  corresponding  word.  A  patient 
ma}^  ask  for  a  spoon,  when  he  means  a  knife,  and  persist 
that  he  is  correct.  Sometimes  this  use  of  wrong  words 
renders  his  conversation  unintelligible. 

Agraphia.  Air. via.  Incapacity  to  convey  thoughts  in 
writing,  as  well  as  in  speech,  is  more  or  less  observed  in 
amnesic  aphasia.  It  is  clear  that  words,  which  cannot 
be  recalled,  can  as  little  be  communicated  in  writing. 
The  agraphia  in  some  patients  is  modified  in  so  far,  that 
they  can  correctly  copy  the  writing  of  others.  Alexia  is 
usually  also  present.  The  written  characters  convey  no 
meaning  to  the  patient.  Finally  it  has  been  noticed  that 
in  aphasia  there  is  sometimes  a  loss  of  the  language  of 


LOCA  L  IZA  TIOX^CEREB  RA  L  DISEA  SES. 


219 


gesticulation  and  pantomime.    Patients  wrongly  indicate 
by  their  gestures  the  intention  they  wish  to  express. 


Topography  of  the  Skull  in  Relation  to  the 
Surface  of  the  Brain. 


FR       Fissure  of  Rolando. 
8^  Fissure  of  Sylvius. 

PI,  P2  Upper  and  lower  parietal 
convolutions. 

Cerebellum. 

Frontal  lobe. 

Parietal  ridge. 

Coronal  suture. 

Fronto-Sphenoidal  fissure. 

Lambdoidal  sutui'e. 


Cb 

F 

R,  R 

C,C 

FS 

LS 


AC  and  PC     Anterior  and  poste- 
rior central  convolutions. 
0         Occipital  lobe. 
T        Temporal  lobe, 
fi        First  frontal. 
f.^         Second  frontal, 
f;.  Third  frontal  convolutions, 

tv        Transverse  vertical  line. 
FB       Angle  of  frontal  bone. 
SS        Squamous  suture. 


The  area  corresponding  to  the  first,  second  and  third 
frontal  convolutions  is  bounded  anteriorly  by  a  trans- 
verse line  ending  at  the  angle  of  the  frontal  bone,  behind 
by  the  coronal  suture  and  below  by  the  fronto-sphenoidal 
fissure. 

The  area  corresponding  to  the  anterior  and  posterior 
central  convolutions  is  bounded  in  front  by  the  coronal 


S^O  MA  N  UA  L   OF  NEIi  VOUS  DIS  EA  S  ES . 

suture,  behind  by  a  parallel  line  intersecting  the  parietal 
ridge  and  below  the  t^quamous  suture.  The  superior  por- 
tion of  the  central  convolutions  is  above  the  parietal 
ridge,  its  inferior  portion  is  below  the  ridge.  The  supra- 
marginal  convolution  corresponds  to  the  region  of  the 
parietal  eminence. 

The  area  of  the  temporal  lobe  is  bounded  above  by  the 
squamous  suture.  The  occipital  lobe  is  bounded  in  front 
bv  the  lambdoidal  suture. 


CHAPTER  XIII. 

DISEASES  OF  THE  BRAIN. 

Cerebral  Hyper.emta. 

(Congestion   of  the    hrain.) 

Etiology.  Circulatory  disturbances  of  the  brain  used 
to  play  an  important  role  in  the  pathology  of  various 
cephalic  symptoms  for  which  no  other  cause  could  be 
assigned.  It  is  not  easy  to  understand  under  what  cir- 
cumstances arterial  hyperaemia  can  occur,  except  it  be 
from  simple  hypertrophy  of  the  left  ventricle  of  the  heart. 
Full-blooded  or  rather  "  plethoric  "  people  are  popularly 
thought  to  be  peculiarly  liable  to  severe  head  affections. 
If  by  the  latter  be  meant  cerebral  haemorrhage  or  cerebral 
embolism  and  it  can  hardly  mean  anything  else,  then 
morbid  anatomy  is  at  fault.  Symptoms  like  headache, 
dizziness,  throbbing  of  the  carotids  and  a  flushed  face 
are  often  enough  seen  after  a  debauch  or  a  heavy  meal  or 
in  states  of  great  mental  excitement.  It  would  not  be 
hazarding  too  much  to  surmise  that  such  causes  tend  to 
lessen  arterial  tension  which  induces  increased  blood 
pressure.  The  condition  thus  induced  is  probably  meant 
by  the  phrase  "  a  rush  of  blood  to  the  head." 

Passive  congestion  of  the  brain  is  better  understood.  It 
is  invariably  a  secondary  affection  resulting  from  imped- 
iment to  the  return  of  blood  from  the  brain.     This  con- 

(  1^21  ) 


222  MA  N  UA  L   OF  NE  RVO  US  D  IS  EA  S  ES . 

dition  occurs  in  cardiac  and  pulmonary  diseases,  which 
obstruct  the  venous  circuhition.  The  face  in  well-marked 
cases  has  a  purplish  tinge  and  the  lips  are  of  a  bluish 
color.  The  head  feels  heavy  and  full,  the  breathing  is 
oppressed,  there  is  a  feeling  of  languor  and  the  patient  is 
indisposed  to  physical  and  mental  exertion.  Now,  a 
brain  that  carries  too  much  venous  blood  is  a  badly  nour- 
ished and  actually  an  anai^mic  brain,  and  the  symptoms 
correspond  with  this  condition. 

Treatment.  Persons  who  are  liable  to  attacks  of  active 
congestion  of  the  brain  should  be  warned  of  the  causes 
that  bring  them  on.  In  the  majority  of  cases  it  suffices 
to  act  briskly  on  the  bowels  and  to  apply  leeches  to  the 
head.  A  course  of  aperient  medicine,  for  which  the  bit- 
ter waters  are  well  adapted,  is  often  of  much  benefit. 

The  treatment  of  venous  hyperaemia  of  the  brain  is 
chiefly  that  of  the  primary  disease.  The  symptoms  may 
be  temporarily  relieved  by  gentle  aperients,  cold  to  the 
head  and  w^arm  footbaths.  Formerly  it  was  the  fashion 
to  practice  abstraction  of  blood  in  these  cases,  and  no 
doubt  it  often  gave  prompt  relief.  One  is  sometimes 
tempted  to  take  up  this  practice  again  under  certain  cir- 
cumstances. Some  years  ago  I  attended  a  young  woman 
who  suffered  from  constant  violent  headache,  flushed 
face  and  heavy  breathing,  that  depended  on  valvular 
obstruction  of  the  heart.  Nothing  else  gave  her  any 
relief  but  venesection,  which,  of  course,  could  not  be 
safely  repeated  as  often  as  she  demanded  it. 

CEREBRAL   ANiEMIA. 

Etiology.  The  sudden  development  of  extreme  cerebral 
anaemia  is  witnessed    in  profuse  hemorrhages,  failure  of 


DISEASES   OF   THE  BRAIX,  223 

the  heart's  action  and  profound  mental  impressions.  It 
is  manifested  by  great  pallor  of  the  face,  loss  of  conscious- 
ness, slow  and  sighing  respiration,  a  feeble  pulse,  dilata- 
tion of  the  pupils,  blackness  before  the  eyes,  sometimes 
vomiting  and  general  convulsions.  The  gradual  estab- 
lishment of  cerebral  anaemia  is  seen  in  chronic  diseases, 
chlorosis,  general  anaemia,  prolonged  lactation  and  debil- 
itating discharges. 

Clinical  History.  The  symptoms  of  chronic  cerebral 
anaemia  consist  of  various  functional  nervous  disorders. 
Headache,  vertigo  and  nausea  are  its  constant  attend- 
ants. Patients  show  mental  irritability  and  complain  of 
languor  and  weakness.  They  are  liable  to  fainting  fits. 
One  of  the  most  unpleasant  symptoms  is  a  feeling  of 
drowziness.  Hallucinations  of  sight  and  hearing  some- 
times develop  in  aggravated  cases.  Many  of  the  ailments 
attributed  to  neurasthenia  are  really  the  effects  of  cere- 
bral anaemia. 

The  Treatment  when  general  anaemia  exists  is  obvious. 
Attention  must  be  particularly  directed  to  the  special 
cause  that  underlies  the  head  symptoms.  A  disregard  of 
the  causal  indications  render  all  the  reputed  nervines 
and  sedatives  of  no  avail. 

CEREBRAL   HEMORRHAGE. 

(Apoplexy.) 
Etiology.  Disease  of  the  coats  of  the  cerebral  blood- 
vessels is  the  chief  cause  of  cerebral  hemorrhage.  The 
degenerative  change  far  more  frequently  consists  of  an 
arterio-sclerosis  than  atheroma.  In  consequence  of  the 
thinning  of  the  vascular  walls,  miliary  aneurisms  develop 
which   on   rupture    permit   the    effusion   of  blood.     The 


^•2Jf  MANUAL  OF  NERVOUS  DISEASES. 

formation  of  these  minute  dilatations  of  cerebral  arteries 
is  favored  by  the  absence  of  the  adventitia.  Charcot  and 
Bouchard  found  miliary  aneurisms  in  every  one  of  the 
seventy-seven  cases  of  cerebral  hemorrhage  they  had 
examined.  Increase  of  blood  pressure  will  certainly  facil- 
itate the  rupture  of  the  aneurisms,  but  arterial  tension 
alone  without  disease  of  the  walls  of  the  vessels  is  insuf- 
ficient to  cause  the  rupture.  There  are  many  exciting 
causes  which  in  consequence  of  increased  blood  pressure 
lead  to  cerebral  hemorrhage.  It  is  a  matter  of  experience 
that  apoplectic  attacks  are  often  seen  after  strong  physical 
efforts.  Even  relatively  slight  exertions,  such  as  cough- 
ing, sneezing  and  especially  straining  at  stool  may  burst 
a  diseased  vessel  of  the  brain.  The  indulgence  in  alcoholic 
stimulants  and  the  use  of  the  cold  plunge-bath  may  be 
followed  by  the  same  consequences,  ^[ental  excitement 
has  sometimes  a  similar  effect. 

Cerebral  hemorrhage  is  also  often  observed  to  occur  in 
hypertrophy  of  the  heart,  especially  in  that  form  of  car- 
diac trouble  which  develops  in  Bright's  disease.  In  those 
cases  characterized  by  the  existence  of  the  granular  con- 
tracted kidney,  the  accompanying  arterio-sclerosis  facili- 
tates the  rupture  of  cerebral  blood-vessels  under  the 
influence  of  the  exaggerated  action  of  the  heart.  In  55 
cases  of  cerebral  hemorrhage  cited  by  Charcot,  hyper- 
trophy of  the  heart  was  found  in  22.  The  kidneys  were 
afif'ected  in  32^  per  cent  of  49  cases. 

Extravasation  of  blood  in  the  brain  has  been  met  with 
in  scurvy,  pernicious  ana?mia  and  leukaemia.  Capillary 
hemorrhage  of  the  brain  occurs  in  cases  of  pernicious 
infectious  diseases,  smallpox,   pya-mia,  etc.      This  acci- 


DISEASES   OF   THE  BRAIN.  225 

dent  is  insignificant  in  comparison  with  the  grave  nature 
of  these  diseases. 

Alcoholism,  syphilis  and  gout  must  also  be  considered 
as  occasional  etiological  factors  of  apoplexy. 

Age  has  a  decided  influence  on  the  occurrence  of  cere- 
bral hemorrhage.  Persons  under  forty  years  are  rarely 
attacked.  Sex  has  a  similar  important  bearing.  The 
proportion  of  men  who  are  subject  to  cerebral  apoplexy 
far  exceeds  that  of  women. 

A  predisposition  to  cerebral  hemorrhage  must  be 
admitted  in  the  sense  that  certain  families  show  a  hered- 
itary tendancy  to  arterial  degeneration.  The  wide-spread 
belief  that  thick-set,  short-necked  men  of  a  florid  com- 
plexion are  prone  to  be  affected  w^ith  cerebral  hemorrhage 
does  not  accord  with  experience. 

Anatomical  Changes.  Certain  parts  of  the  brain  are  more 
often  subject  to  hemorrhage  than  others.  Those  parts  in 
the  vascular  districts  supphed  by  the  middle  cerebral 
artery  are  especially  frequent  situations  of  blood  clots. 
They  include  in  the  order  of  frequency,  the  caudate  and 
lenticular  nuclei,  the  thalamus  optici,  the  internal  cap- 
sule and  centrum  ovale.  Hemorrhage  of  the  convolu- 
tions, the  pons  and  cerebellum  is  much  less  frequent. 
The  crura  cerebri  and  the  medulla  are  very  rarely 
affected.  The  blood  sometimes  makes  its  way  into  a 
ventricle  or  escapes  to  the  surface  of  the  brain.  It  always 
tears  up  the  brain  tissue  and  then  forms  into  a  clot. 
The  blood  clots  are  of  various  sizes  in  different  cases  ; 
they  may  not  exceed  the  size  of  a  pea  or  be  as  large  as  a 
man's  fist.  Very  large  hemorrhages  flatten  the  convolu- 
tions. 

15 


^26  M  ANU  AL   OF  NERVO  US  D I S  EA  S  ES . 

A  recent  clot  presents  the  appearance  of  a  dark,  pitchy 
mass,  which  is   composed  of  the  effused  blood  and   the 
debris   of  the   destroyed  brain  tissue.     The   contiguous 
portion  of  the  brain  is  infiltrated  with  blood  and  is  soft- 
ened.    The  edges  of  the  cavity  where  the  clot  lodges  are 
ragged  and  irregular.     The  clot  itself  undergoes  certain 
changes.     It  is  gradually  absorbed  and  the  surrounding 
parts  tend  to  resume  their  normal  condition.     New  con- 
nective  tissue    develops  in    the  cavity  which  gradually 
forms    a   cyst  containing  an  ochre  colored  fluid.     Such 
an  apoplectic  cyst  is  often  found  in  old  cases   of  cere- 
bral hemorrhage.     Sometimes  the  fluid  contents  of  the 
cvst  are  absorbed,  so  that  nothing  remains  but  a  cicatrix 
of  a  rusty  color,  from  the  intermixture  of  blood  pigment. 
Clinical  History.     A  person  is  said  to  be  threatened  with 
apoplexy   when  certain  symptoms  or   "  w^arnings"  make 
their  appearance.    Such  premonitory  symptoms  are  iden- 
tical  with  those  ascribed  to  cerebral  congestion.     It  is 
probable  they  are  observed  in  cases  where  the  hemorr- 
hage begins  with  a  slow  escape  of  blood.     The  onset  of 
the  apoplectic  attack   may  be  protracted  if  only  a   small 
twig  of  an  artery  ruptures.    But  cerebral  hemorrhage  that 
develops  slowly  is  often  fatal.     The  patient  begins  to  feel 
dizzv  and   nauseous,  his  gait  is. unsteady,  or  his   body 
inclines   to  one    side;  his    mind   becomes   confused,   his 
speech  is  thick,  he  feels  drowsy  and  finally  the  stupor  is 
succeeded  by  profound  coma. 

Sometimes  the  apoplectic  condition  is  absent  and 
hemiplegia,  whether  complete  or  partial,  is  the  first  sign 
of  the  hemorrhage.  The  compression  exerted  by  the  clot 
in  such  a  case  is  supposed  to  be  insignificant.  At  autop- 
sies in  cases  of  this  description  clots  of  no  larger  size 


DISEASES  OF  THE  BRAIN.  221 

than  a  hazel-nut  were  found.  In  case  II  of  "  Andral'e 
Observations"  the  hemorrhage  occurred  without  an 
apoplectic  attack.  The  seat  of  the  clot  was  in  the  optic 
thalamus,  of  the  size  of  a  large  cherry.  Rosenstein 
reports  a  case  in  which  neither  unconsciousness  nor 
paralysis  occurred,  but  only  motor  aphasia.  A  coagulum 
of  blood  of  the  size  of  a  hazel-nut  occupied  the  white  sub- 
stance of  the  third  left  frontal  convolution. 

Ingravescent  apoplexy  is  a  form  of  cerebral  hemorrhage 
characterized  by  the  peculiarity  that  fatal  coma  develops 
for  hours  or  several  days  subsequent  to  the  appearance  of 
hemiplegia  and  head  symptoms.  In  cases  published  by 
Broadbent,  the  hemorrhage  had  begun  in  different  parts 
of  the  brain  and  later  either  burst  into  the  ventricle  or 
broke  through  the  pia. 

Delayed  apoplexy  differs  from  the  foregoing  in  the  circum- 
stance that  the  symptoms  develop  gradually.  There  is 
headache,  dizziness,  nausea,  delirium  ;  one  arm  or  one 
leg  or  the  whole  of  one  side  is  paralyzed  and  finally  uncon- 
sciousness sets  in.  The  hemorrhage  in  such  cases  accu- 
mulates slowly  until  the  amount  of  the  effused  blood 
brings  on  coma. 

In  severe  attacks  of  cerebral  hemorrhage  there  are 
no  premonitory  symptoms,  the  patient  is  suddenly 
and  unexpectedly  thrown  into  a  condition  of  profound 
unconsciousness  and  utter  insensibility.  In  popular 
language  he  has  a  "  stroke  of  apoplexy."  The  patient 
may  sometimes  have  just  time  enough  to  lie  down  or 
sink  into  a  chair  before  he  becomes  completely  comatose. 
He  presents  then  the  following  appearance  :  The  face  is 
flushed,  the  eyes  are  watery,  the  pulse  is  full,  but  often 
slow,  the  respiration  is  noisy  or  stertorious,  the  mouth  is 


Q28  MA  X UAL   OF  NER  V 0  US  DISEA  S ES . 

drawn  in  with  each  inspiration  and  the  cheeks  bulge  out 
with  every  expiration.  Many  patients  in  this  condition 
rapidly  sink.  The  temperature  is  seldom  altered,  but 
immediately  before  the  fatal  termination  it  may  quickly 
rise  or  fall.  In  very  bad  cases  there  is  sometimes  lateral 
deviation  of  the  eyes  and  rotation  of  the  head  in  the 
same  direction.  There  is  no  characteristic  change  of  the 
pupils.  They  may  be  normal,  contracted  or  dilated. 
Whilst  the  patient  is  in  the  comatose  condition  there  is 
complete  relaxation  of  the  muscles. 

Examination  of  the  urine  after  an  ordinary  apoplectic 
attack  frequently  detects  traces  of  albumen  and  sugar. 
Quite  often  there  is  retention  of  urine. 

Many  patients  never  recover  from  the  initial  symptoms 
of  cerebral  hemorrhage.  In  this  condition  all  the  vital 
functions  begin  to  fail.  The  stertor  is  replaced  by  rat- 
tling in  the  throat,  the  saliva  runs  down  the  chin,  the 
respiration  becomes  exceedingly  shallow,  the  body  feels 
cool,  the  pulse  is  very  slow  and  feeble  or  extremely  rapid, 
the  eyes  are  sunk  deeply  into  their  sockets,  the  cornea  is 
opaque,  the  face  is  pallid  and  the  cheeks  are  fallen  in. 
Death  may  happen  within  an  hour  or  the  patient  may 
linger  for  a  day  or  two. 

A  more  favorable  termination  is  however  witnessed  in 
a  large  proportion  of  cases.  Consciousness  gradually 
returns,  the  patient  gives  signs  of  the  clearing  of  the 
intelligence,  he  opens  his  eyes,  looks  around,  changes  his 
position  and  soon  recognizes  those  that  surround  him. 
The  amount  of  damage  done  to  the  brain  after  the  subsi- 
dence of  the  shock  can  now  be  judged  by  the  severity  of 
the  hemiplegia. 

The  distinction  between  direct  and  indirect  symptoms 


DISEASES  OF   THE  B H A  I N .  229 

of  cerebral  hemorrhage  is  of  practical  importance. 
Hemiplegia  is  eminently  the  symptom  which  •  represents 
the  direct  effect  of  the  focal  lesion,  but  it  may  be  an 
indirect  symptom  if  the  pyramidal  tract  is  only  second- 
arily implicated.  The  coma,  which  often  quickly 
disappears  in  favorable  cases,  is  evidently  a  cortical 
symptom,  and  is  the  result  of  shock  or  compression.  As 
it  occurs  wherever  the  clot  may  be  situated  in  the  brain, 
the  impaired  consciousness  must  be  considered  in  the 
light  of  an  indirect  symptom.  But  coma  may  have  the 
significance  of  a  direct  symptom,  when  the  lesion  affects 
the  prefrontal  lobe.  It  may  be  stated  in  general  terms 
that  those  symptoms  are  of  a  direct  character  that  denote 
permanent  disturbance  of  special  function's  of  the  brain. 
Those  are  of  an  indirect  character  which  are  transitory 
and  subordinate.  We  know  from  experience  the  tempo- 
rary nature  of  certain  symptoms  that  attend  cerebral 
hemorrhage,  but  often  we  are  only  able  to  determine 
their  true  character  by  the  future  course  of  the  individual 
case.  Under  the  head  of  indirect  symptoms  are  usually 
included:  disturbance  of  speech;  early  rigidity,  transitory 
aphasia;  changes  of  the  urinary  secretion;  deviation  of 
the  eyes  and  myopia.  The  facial  paralysis  in  hemiplegia 
is  quite  often  an  indirect  symptom. 

Hemiplegia  is  the  clinical  evidence  of  injury  or  indirect 
implication  of  the  pyramidal  tract  iir  any  part  of  its 
course  in  the  brain.  As  the  lesion  in  cerebral  hemorrhage 
in  the  large  proportion  of  cases  involves  the  central  gan- 
glia and  adjacent  parts,  it  is  obvious  that  the  internal 
capsule  being  almost  invariably  involved  necessarily  gives 
rise  to  hemiplegia  of  the  side  opposite  to  the  lesion. 

The  paralysis  of  the  extremities  is  the  most  important 


230  MA  N  UAL   OF  XER  VOUS  D  IS  EA  SES . 

feature  of  hemiplegia.  In  some  cases  there  is  total 
paralysis  of  the  arm  and  leg.  In  others  there  may  only 
exist  a  slight  hemiparesis.  A  variable  degree  of  improve- 
ment of  the  paralysis  takes  place  in  numerous  cases.  It 
sometimes  appears  so  early  and  well  marked  that  prob- 
ably the  paralysis  to  a  great  extent  was  an  indirect 
symptom.  But  usually  the  improvement  is  only  partial. 
It  begins  as  a  general  rule  in  the  inferior  extremity. 
Many  patients  are  again  able  to  walk  with  the  weak  leg, 
whilst  the  arm  is  still  useless.  Paralysis  of  the  face  is 
usually  not  a  prominent  symptom  in  cerebral  hemiplegia. 
It  is  confined  to  the  muscles  supplied  by  the  lower  division 
of  the  facial  nerve,  and  may  be  so  slight  that  it  is  only 
recognized  when  the  patient  smiles  or  shows  his  teeth. 
In  impairment  of  the  hypoglossus,  the  tip  of  the  tongue 
inclines  towards  the  paralyzed  side.  The  soft  palate  is 
sometimes  affected.  It  hangs  lower  down,  and  is  also 
directed  towards  the  paralyzed  side. 

The  tendon  reflexes  in  nearly  all  cases  of  hemiplegia 
are  exaggerated  on  the  affected  side.  Vigorous  contrac- 
tions are  excited  when  the  tendons  and  bones  of  the  arm 
and  the  leg  are  tapped.  On  the  other  hand  the  cutaneous 
reflexes  are  always  diminished  on  the  hemiplegic  side. 

Sensation  is  rarely  impaired.  Hemianesthesia  in 
connection  with  hemiplegia  is  observed  in  lesion  of  the 
inferior  third  of  the  internal  capsule. 

Contraction  of  the  paralyzed  muscles  is  often  seen  in 
the  late  stage  of  hemiplegia.  This  "late  rigidity"  affects 
the  upper  extremity  more  than  the  lower.  The  fingers 
are  fixed  in  the  position  they  assume  when  at  rest;  the 
upper-arm  is  adducted  by  the  pectorales  major  and  the 
forearm  is  in    pronation.     Moderate  contraction   of   the 


DISEASES   OF   THE  BRAIN.  231 

calf  muscles  of  the  leg  is  occasionally  observed.  It  is 
held  that  the  muscular  rigidity  in  hemiplegia  is  due  to 
secondary  degeneration  of  the  pyramidal  tract.  "Asso- 
ciated movements"  constitute  occasionally  interesting 
phenomena  of  hemiplegia.  It  is  observed  that  move- 
ments of  the  paralyzed  mut^cle^;  are  excited  when  volun- 
tary movements  are  carried  out  by  the  healthy  side. 
Post-hemiplegic  chorea  is  a  rare  symptom  of  cerebral 
hemorrhage. 

Vaso-motor  symptoms  are  observed  soon  after  the 
apoplectic  attack.  The  paralyzed  limbs  are  warmer  and 
redder  than  those  of  the  healthy  side.  Congestion  and 
even  effusion  of  blood  into  the  lung,  pleura,  endocardium 
and  kidneys  has  been  found  in  fatal  cases. 

By  the  trophic  symptoms  in  hemiplegia  are  under- 
stood the  development  of  malignant  bed  sores  and  painful 
joint  disease. 

Atrophy  of  the  paralyzed  muscles  is  noticed  in  old 
standing  cases  of  hemiplegia,  but  it  is  not  of  the  degen- 
erative sort.  The  faradic  reaction  of  the  muscles  is 
normal. 

Impairment  of  the  mental  capacity  in  hemiplegia 
patients  is  sometimes  very  evident.  It  may  escape  notice, 
when  they  engage  in  ordinary  affairs  of  life,  but  they  are 
often  incapable  of  sustained  intellectual  efforts.  The 
mental  weakness  is  usually  recognized  by  forgetfulness  of 
recent  events  and  the  undue  display  of  emotional  excite- 
ment. Old  paralytics  are  frequently  seen  to  weep  or 
whimper  without  any  apparent  provocation. 

Bastian  gives  the  limit  of  four  weeks,  beyond  which 
time  little  improvement  of  the  paralysis  may  be  expected. 
The  general  health  is  often  fairly  good,  and  many  hemi- 


232  MA  XL' A  L   0  F  NEB  VO  US  D  I  SEA  SES. 

plegic  patients  grow  even  corpulent.  Later  on,  when 
they  become  bedridden  and  marasmus  develops,  they 
are  apt  to  succumb  to  slight  intercurrent  affections. 

Diagnosis.  The  differential  diagnosis  between  cerebral 
hemorrhage  and  cerebral  embolism  will  be  discussed  in 
connection  with  the  latter  disease.  Although  cerebral 
apoplexy  presents  the  striking  phenomenon  of  sudden 
loss  of  consciousness,  which  in  the  majority  of  cases  ren- 
ders diagnosis  easy,  yet  the  recognition  of  the  true  state 
of  the  case  may  remain  uncertain  in  instances  of  very 
rapid  death,  say  within  half  an  hour  or  less.  Cerebral 
hemorrhage  does  not  usually  kill  instantly.  Such  a 
mode  of  death,  preceded  by  coma,  is  more  likely  to  be 
due  to  meningeal  hemorrhage  from  a  traumatic  cause, 
the  rupture  of  an  aneurism  or  sudden  failure  of  the  heart's 
action  in  valvular  disease.  The  most  embarrassing  cases 
however  are  those  in  which  persons  of  whose  previous  his- 
tory nothing  is  known  are  found  in  a  state  of  coma  resem- 
bling that  of  cerebral  hemorrhage.  Suppose  a  man  deeply 
comatose  is  picked  up  in  the  street  by  a  policeman,  or  a 
stranger  at  a  hotel  is  found  in  a  complete  state  of  stupor, 
from  which  he  cannot  be  roused,  it  would  be  hazardous 
to  express  a  positive  opinion  concerning  the  true  condition 
of  such  a  patient.  If  in  an  instance  of  this  kind  the 
patient  is  advanced  in  years,  if  the  artery  at  the  wrist  is 
rigid,  or  the  signs  of  cardiac  or  renal  disease  are  evident, 
there  is  great  probability  that  the  loss  of  consciousness  is 
either  the  effect  of  cerebral  hemorrhage  or  embolism. 
Still  this  does  not  exclude  the  possibility  of  injury  to  the 
head,  deep  intoxication,  opium  poisoning,  ur^emic  or 
epileptic  stupor  or  meningitis.  It  has  often  happened 
that  the  extreme  prostration  presented  by  a  drunken  man 


DISEASES   OF   THE  BRAIN.  233 

has  induced  compassionate  people  to  ply  him  with  brandy, 
and  contrariwise  a  man  with  a  clot  in  his  brain  has 
sometimes  been  arrested  by  the  police  on  the  charge  of 
drunkenness.  If  paralysis  co-exists  the  difficulty  of  diag- 
nosis vanishes  at  once,  for  whatever  may  have  been  the 
mode  of  onset,  there  is  some  lesion  of  the  brain  in  the 
case.  Very  confusing  complications  occasionally  arise 
that  tend  to  lead  diagnosis  astray,  as  illustrated  in  the 
history  of  the  following  case:  A  man  profoundly  coma- 
tose was  sent  from  the  police  station,  where  he  had  been 
placed  in  a  cell  the  previous  night,  to  the  hospital.  The 
house  surgeon  was  informed  that  the  man  was  seen  in  a 
deep  state  of  intoxication,  led  about  by  a  companion,  and 
that  he  had  a  heavy  fall  on  the  curbstone.  As  he  was 
still  unconscious  in  the  morning  and  could  not  be  roused 
he  was  brought  to  the  hospital  in  a  patrol  wagon.  There 
was  a  strong  smell  of  liquor  about  the  man.  The  house 
surgeon  on  examination  discovered  no  injury,  and  con- 
cluded that  from  all  appearances  more  time  would  be 
required  for  the  effects  of  intoxication  to  pass  off.  The 
man  died  three  hours  afterwards.  At  the  autopsy  an 
enormous  meningeal  hemorrhage  and  a  linear  fracture  of 
the  skull  were  found.  Undoubtedly  the  fracture  which 
caused  the  hemorrhage  resulted  from  the  fall  during  the 
state  of  intoxication. 

Prognosis.  Whether  a  patient  who  is  down  with  cerebral 
apoplexy  will  come  out  of  it  or  not  depends  on  the  mild- 
ness or  gravity  of  the  onset,  or  rather  upon  the  quantity 
or  localization  of  the  hemorrhage.  If  the  coma  be  not 
profound  and  the  insensibility  incomplete;  if  there  is  little 
or  no  stertor  and  the  pulse  and  temperature  keep  within 
normal  limits,  the  pati-ent  in  all  probability  will  recover 


.?S4  MA  N  UA  L  OF  ^'ER  VO  US  BISEA  S ES . 

from  the  coma.  The  case  is  unpromising  if  the  uncon- 
sciousness is  profound;  if  there  is  marked  and  persistent 
stertor,  shallow  breathing,  a  retarded  or  irregular  pulse,  or 
a  sudden  rise  or  sinking  of  the  temperature.  A  cautious 
prognosis  must  be  given  in  regard  to  the  future  improve- 
ment of  the  paralysis,  for  it  cannot  be  determined  before- 
hand how  much  of  the  hemiplegia  is  a  direct  or  an 
indirect  symptom.  The  chances  whether  a  patient  who 
safely  got  over  one  attack  of  cerebral  apoplexy  will  have 
another  are  much  against  him  if  his  arteries  are  diseased 
or  his  heart  or  kidneys  are  affected. 

Treatment.  The  routine  practice  of  venesection  in  every 
case  of  cerebral  hemorrhage  is  now  generally  abandoned, 
and  for  good  reasons.  Numerous  patients  recover  from 
the  shock  for  whom  nothing  has  been  done  in  the  way  of 
active  treatment.  There  are,  nevertheless,  exceptional 
cases  in  which  benefit  may  be  expected  from  blood-letting, 
though  it  requires  much  tact  and  judgment  to  select 
them.  The  following  symptoms  in  a  young  individual 
may  indicate  abstraction  of  blood :  a  cyanotic  appearance 
of  the  face,  a  hot  head,  injected  eyes,  a  vigorous  pulse 
and  a  labored  respiration.  Leeches  on  the  temples  or  on 
the  mastoid  processes  may  suffice  in  elderly  persons. 
Active  purgation  from  the  effects  of  a  few  drops  of  croton 
oil  mixed  with  a  little  syrup  or  a  stimulant  enema 
deserve  a  trial  when  the  coma  is  very  prolonged.  An 
opposite  treatment  is  advisable  when  there  is  great  pallor 
of  the  face,  a  low  temperature,  a  feeble  pulse,  slow  and 
shallow  respiration  and  widely  dilated  pupils.  Patients 
in  this  condition  are  in  danger  of  sinking  rapidly,  though 
often  nothing  can  be  done  to  prevent  it.  Wine,  brandy, 
ether,  musk  and  camphor  should  be  steadily  administered 


DIS EA  S ES   OF   THE  BRA  I  N.  235 

against  the  threatened  collapse.  Should  the  patient  be 
unable  to  swallow,  which  is  usually  the  case,  some  of 
these  remedies  may  be  given  with  the  hypodermic  syringe. 
The  failing  respiration  may  be  excited  by  dashing  cold 
water  on  the  face  and  bare  chest;  the  skin  may  be  rubbed 
with  dry  mustard  or  sinapisms  be  applied  to  the  insides 
of  the  arms  and  thighs. 

It  suffices  in  ordinary  cases  of  cerebral  hemorrhage  to 
place  the  patient  in  a  comfortable  position,  to  raise  the 
head  and  shoulders  and  to  keep  off  all  disturbances  from 
bystanders.     An  icebag  should  be  applied  to  the  head. 

Formerly  a  great  variety  of  remedies  were  employed 
with  the  object  of  promoting  the  absorption  of  the  clot. 
The  futility  of  meddling  wdth  the  clot  is  now  better  under- 
stood. Confidence  in  the  recuperative  powers  of  nature 
to  restore  in  some  measure  the  damage  done  to  the  brain 
is  fully  justified  by  the  improvement  of  the  paralysis 
which  is  often  witnessed.  Much  can  be  done  to  prevent 
or  retard  the  renewal  of  the  hemorrhage,  with  which  the 
patient  is  always  threatened,  by  measures  that  invigorate 
the  general  system.  Patients  should  be  advised  to  abstain 
from  heavy  meals,  and  from  physical  strains  and  mental 
overwork.  The  paralysis  is  often  of  such  long  duration 
that  the  physician  should  not  neglect  to  continue  an 
appropriate  treatment,  which  prevents  the  recurrence  of  an 
apoplectic  attack.  A  judicious  symptomatic  treatment 
after  the  shock  has  passed  off  relieves  a  number  of  dis- 
tressing symptoms  that  more  or  less  affect  paralytic 
patients.  Troublesome  headache  is  sometimes  promptly 
relieved  by  a  blister  behind  the  ears  or  nape  of  the  neck. 
Insomnia  may  require  chloral  and  bromide  of  potassium 
or  an  occasional  small  dose  of  morphia.     Sometimes  a 


S36  M A X UAL  OF  XER  VO  US  DfSEA  SES . 

nightly  rum  punch  does  better  in  old  paralytics,  but 
large  and  often-repeated  quantities  of  alcohol  do  mischief. 
At  the  end  of  about  four  weeks,  after  all  the  initial 
symptoms  have  subsided,  a  systematic  course  of  elec- 
tric treatment  is  the  only  therapeutic  measure  from 
which  improvement  of  the  paralysis  can  be  expected, 
although  it  would  be  difficult  to  decide,  in  favorable  cases, 
what  share  the  electricity  had  in  the  improvement.  A 
feeble  galvanic  current  should  be  cautiously  passed  trans- 
versely through  the  head  for  about  two  minutes  in  a 
position  corresponding  to  the  hemorrhagic  focus.  Strok- 
ing the  paralyzed  muscles  with  the  kathode  of  the 
galvanic  current  is  also  advisable. 

HEMIPLEGIA  IN  CHILDHOOD. 

There  is  much  uncertainty  in  regard  to  the  primary 
cause  of  cerebral  hemiplegia  in  children.  The  post- 
mortem appearances  that  are  observed  after  the  disease 
has  existed  for  a  considerable  time  show  the  effects  of 
a  pathological  process  that  led  to  loss  of  substance  of  the 
brain  (porencephalia).  The  degeneration  of  brain  tissue 
implicates  the  motor  tract.  Probably  the  origin  of  the 
morbid  change  varies  in  different  cases.  It  may  have 
been  hemorrhage,  thrombosis,  embolism  or  a  congenital 
defect.  Strum  pel  describes  the  disease  under  the  name  of 
''the  acute  encephalitis  of  children,"  and  considers  it 
analogous  to  the  acute  poliomyelitis  of  the  same  class  of 
patients.  The  disease  attacks  children  between  one  and 
six  years  of  age,  wht)  had  previously  been  in  good  health. 
It  is  sometimes  seen  to  follow  exanthematous  diseases. 

Clinical  History.  The  hemiplegia  in  some  cases  is  pre- 
ceded by  grave  cerebral  symptoms,  fever,  nausea,  vomit- 


DISEASES   OF   THE  BRAIN.  237 

ing,  stupor  and  general  convulsions.  After  the  subsidence 
of  these  symptoms  the  little  patient  is  seen  to  be  para- 
lyzed on  one  side.  The  hemiplegia  gradually  improves, 
but  complete  restoration  is  unusual.  The  arm  is  always 
more  affected  than  the  leg,  but  both  limbs  are  arrested  in 
their  growth.  The  reflexes  are  exaggerated,  contractures 
develop  and  the  paralyzed  muscles  atrophy.  Sensory 
disturbances  are  absent.  Symptoms  of  motor  irritation 
are  observed  in  old  standing  cases,  resembling  hemichorea 
and  athetosis.  In  some  cases  there  is  a  relaxed  condition 
of  the  metacarpal  articulations  that  permits  the  fingers 
to  be  placed  in  positions  at  right  angles  with  the  back  of 
the  hand.  Epileptiform  convulsions  develop  at  a  late 
period.  Sometimes  impairment  of  the  intelligence  occurs, 
especially  on  the  side  of  the  moral  instinct. 

Treatment.  During  the  acute  stage,  when  the  diagnosis 
is  of  course  uncertain,  the  object  of  treatment  is  the 
mitigation  of  the  cerebral  excitement.  Leeches  may  be 
applied  to  the  temples  or  mastoid  process,  followed  by 
cold  to  the  head  and  a  calomel  purge.  After  the  hemi- 
plegia has  become  stationary,  there  is  little  to  be  expected 
from  therapeutical  measures.  Improvement  has  been 
claimed  in  some  cases  from  the  iodide  of  potassium. 
Electricity  and  massage  may  possibly  be  of  benefit. 

CEREBRAL  EMBOLISM  AND  THROMBOSIS. 

(Softening  of  the  Brain  from  Occlusion  of  Cerebral 
Arteries.) 
Etiology.  The  usual  sources  of  embolism  are  thrombi  of 
the  left  auricle,  concretions  of  the  arch  of  the  aorta,  and 
very  frequently  particles  of  matter  that  detach  from 
fibrinous  masses  on  the  valves  of  the  left  ventricle  of  the 


238  MA  N  UAL   OF  NER  V  0  US  D  IS  EA  S  ES . 

heart  dating  from  a  previou;^  endocarditis.  The  eniboU 
on  being  washed  away  by  the  circulation,  are  carried  to 
cerebral  arteries  and  occlude  them.  Thrombi  originate 
in  diseased  blood-vessels.  If  they  develop  in  the  cerebral 
arteries  they  directly  produce  occlusion.  In  the  latter 
situation  they  often  crumble  and  become  thus  another 
source  of  embolism.  The  blood-vessels  in  which  the 
thrombi  originate  are  either  affected  with  arterio-sclerosis 
atheroma  or  syphilitic  endarteritis.  Sluggishness  of  the 
circulation,  which  favors  the  stagnation  of  blood,  is  an 
important  factor  in  the  development  of  thrombosis. 

If  the  collateral  circulation  is  established  which 
replaces  the  arterial  blood  cut  off  by  embolism  in  a  cer- 
tain vascular  territory  of  the  brain  no  harm  results,  but 
if  this  does  not  occur  it  must  necessarily  happen  that  the 
part  of  the  brain  deprived  of  its  blood  supply  softens  and 
breaks  down.  Emboli  are  more  frequently  arrested  in 
the  large  basal  ganglia  and  the  internal  capsule  than 
in  other  parts  of  the  brain.  This  is  due  to  the  circum- 
stance that  those  regions  of  the  brain  are  supplied  by 
branches  of  the  middle  cerebral  artery,  which  sparingly 
anastomose.  The  left  middle  cerebral  artery  is  rather 
more  frequently  affected  than  the  right. 

The  process  of  softening  in  cerebral  embolism  takes  the 
same  course  as  embolism  of  the  lung,  spleen  and  kidney, 
but  no  infarcti  are  formed.  It  begins  with  ana'mia  of  the 
area  of  the  brain  that  has  been  occluded,  which  is  soon 
followed  by  disintegration  of  the  affected  brain  tissue 
until  it  is  reduced  to  a  pulpy  mass.  A  focus  of  softening 
may  present  a  reddish  appearance  from  the  intermixture 
of  blood  of  neighboring  vessels,  or  it  is  of  a  white  or 
yellowish    color.       A    recent    spot   of    softening,    when 


DISEASES  OF  THE  BRAIN.  239 

examined  with  the  microscope,  is  seen  to  consist  of  the 
debris  of  the  destroyed  nerve  elements  and  vestiges  of 
neuroglia  and  vessels.  Changes  analogous  to  those  tak- 
ing place  in  the  blood  clot  of  cerebral  hemorrhage  are 
observed  in  the  dead  brain  tissue  so  that  it  is  diffi- 
cult to  make  the  distinction  in  old  cases.  The  disinte- 
grated mass  is  absorbed  and  replaced  by  cicatrical  tissue, 
which  hardens  and  atrophies  the  convolutions.  Deep 
depressions  are  found  when  the  softening  occurs  on  the 
surface  of  the  brain. 

Clinical  History.  An  apoplectic  attack  is  often  the  first 
intimation  of  the  occurrence  of  cerebral  embolism  in  indi- 
viduals whose  general  health  had  previously  appeared  to 
be  good.  The  loss  of  consciousness  may  be  as  complete 
and  come  on  as  suddenly  as  in  cerebral  hemorrhage, 
though  it  is  more  frequently  ushered  in  by  general  con- 
vulsions, delirium  or  vomiting.  But  the  onset  may  be 
slow  and  the  coma  incomplete.  Patients  can  be  roused 
for  a  moment,  they  look  about  and  may  answer  ques- 
tions, but  soon  fall  back  again  into  the  former  dazed 
condition.  This  difference  in  the  severity  of  the  onset 
probably  depends  on  the  size  of  the  artery  that  is 
occluded. 

The  onset  in  thrombosis  is  usually  slow  and  made  up 
of  frequent  attacks  of  vertigo,  faintness  and  mental  weak- 
ness. This  condition  is  generally  seen  in  elderly  people 
who  have  previously  shown  evidences  of  failing  health 
or  in  those  who  have  exhibited  signs  of  premature  senile 
decay.  A  deterioration  of  the  physical  and  intellectual 
powers  may  have  been  noticed  for  weeks  or  months  before 
the  final  breakdown.  There  is  often  much  headache, 
dizziness,  unsteadiness  of  gait,  a  tendency  of  the  ])ody  to 


240  MA  X  UA  L   OF  XER  VO  US  DIS  EA  SES . 

lean  to  one  side,  now  and  then  a  marked  incoherence  of 
speech,  or  rather  a  misplacement  of  words,  a  feeble  mem- 
ory, and  sensations  of  numbness  and  formication  in  some 
of  the  limbs.  These  prodromic  symptoms  may  never 
develop  into  an  apoplectic  seizure,  l)ut  there  is  a  history 
of  occasional  paresis  of  the  face,  weakness  of  an  arm  or 
of  a  leg,  mental  impairment  and  finally  senile  dementia. 
The  spots  of  softening  found  in  the  brain  in  cases  of  this 
kind  result  from  thrombosis  of  atheromatous  arteries. 
Heubrier  observed  obliterated  cerebral  arteries  from 
thrombosis   in  syphilitic  young  persons. 

The  abrupt  development  of  the  apoplectic  coma  in 
cerebral  embolism  and  thrombosis  does  not  admit  of  an 
easy  explanation,  and  the  same  applies  to  the  rather 
frequent  occurrence  of  epileptiform  spasms.  Probably 
these  symptoms  depend  on  the  sudden  obstruction  of  a 
large  arterial  branch.  A  fatal  termination  may  as 
quickly  follow  the  onset  as  it  does  in  cerebral  hemor- 
rhage, but  patients  have  often  been  seen  to  continue  for 
days  in  an  apparent  precarious  condition  of  unconscious- 
ness and  still  recover. 

The  chronic  course  of  softening  requires  no  separate 
description,  as  there  is  a  history  of  hemiplegia  and  acces- 
sory symptoms  analogous  to  those  of  cerebral  hemor- 
rhage. 

Diagnosis.  However  difficult  and  often  impossible  it 
may  be  to  make  the  distinction  between  the  clinical  his- 
tory of  softening  and  hemorrhage  of  the  brain,  there  are 
certain  considerations  and  points  of  differential  diagnosis 
that  tend  to  turn  the  balance  in  favor  of  the  one  or 
the  other.  The  apoplectic  condition  is  frequently  as 
well    pronounced    in    cerebral    embolism    as    in   hemor- 


D  I S  EA  S  ES  OF  THE  BR  A  IN.  21^1 

rhage,  but  its  prolonged  duration  is  of  less  serious 
import  in  softening.  2.  A  severe  onset,  accompanied  by 
a  flushed  face  and  strong  pulsation  of  the  carotids,  indi- 
cates hemorrhage  rather  than  embolism.  3.  Coma  is 
more  likely  to  be  due  to  embolism  than  hemorrhage  if 
the  patient  be  a  young  person,  especially  if  there  is  a 
history  of  syphilis  or  inflammatory  rheumatism.  4. 
Mental  disturbance  is  more  common  in  occlusion  than  in 
clot.  5.  A  hemiplegia  which  disappears  in  a  few  days 
can  hardly  be  due  to  hemorrhage,  for  it  is  far  more  prob- 
able that  a  paralysis  in  such  a  case  resulted  from 
embolism  that  passed  off"  as  soon  as  the  collateral  circu- 
lation was  established.  6.  Thrombosis  may  be  inferred  to 
exist  in  syphilitic  patients  and  in  senile  softening  when 
the  physical  and  mental  deterioration  slowly  develops. 

Prognosis.  Although  patients  often  recover  from  the 
immediate  effects  of  cerebral  embolism,  they  are  liable  to 
its  recurrence,  as  the  one  attack  shows  the  existence  of 
diseased  blood-vessels.  Even  if  no  other  attack  follows 
they  enter  upon  the  stage  of  chronic  softening,  which 
may  last  for  years,  but  tends  to  a  fatal  termination. 

Treatment.  If  it  were  possible  to  determine  with  certainty 
in  a  case  of  cerebral  apoplexy  the  existence  of  embolism 
or  thrombosis,  eff'orts  might  be  made,  b}^  means  of  stimu- 
lants to  restore  the  circulation  in  the  affected  part  of  the 
brain.  But  it  involves  a  great  risk  to  ply  the  patient 
with  brandy  when  a  hemorrhage  may  possibly  be  going  on. 
Beyond  good  nursing  and  paying  attention  to  the  secre- 
tions, but  little  can  be  done,  after  the  subsidence  of  the 
initial  symptoms.  The  special  treatment  of  the  paralysis 
is  the  same  as  that  detailed  in  the  previous  section  on 
hemiplegia. 


2Jf2  MA  N UA  L  OF  KER  VO  US  D IS EA  SES . 

CEREBRAL   TUMORS. 

Etiology.  Intracranial  tumors  are  of  the  same  histo- 
logical structure  as  neoplasms  in  other  parts  of  the  body, 
and  their  cause  is  as  little  known.  Adventitious  growths 
develop  in  persons  who  have  shown  no  signs  of  impaired 
health.  Men  in  the  middle  period  of  life  are  oftener 
affected  than  women.  The  solitary  tubercle  is  the  tumor 
usually  found  in  children. 

Varieties  of  Cerebral  Tumor. 

1.  Glioma.  This  tumor  consists  of  a  hyperplastic 
growth  of  the  connective  tissue  of  the  brain,  variable  in 
size,  of  a  grayish  or  reddish  color,  seldom  sharply  defined 
and  often  very  vascular,  so  as  to  give  rise  to  hemorrhage. 
Gliomata  usually  occur  in  the  medullary  substance,  and 
often  also  in  the  central  ganglia. 

2.  Sarcoma.  The  various  forms  of  sarcoma  generally 
develop  in  the  dura  mater  and  periosteum  of  the  skull, 
most  frequently  at  the  base,  where,  in  consequence  of  the 
irritation  and  compression  exerted  on  the  parts  in  that 
region  of  the  brain,  very  marked  symptoms  arise. 
Total  blindness  of  one  eye  in  connection  with  paralysis 
of  ocular  muscles  occurs  in  sarcoma  and  glioma  of  the 
orbit. 

3.  Tubercle.  Solitary  and  multiple  tubercle  invade 
different  parts  of  the  brain,  but  more  frequently  the 
cortex,  the  cerebellum  and  the  pons.  These  tumors  are 
usually  of  the  size  of  a  cherry,  but  sometimes  as  large  as 
a  hen's  egg.  Before  the  discovery  of  the  tuliercle  bacilli 
it  was  difficult  to  distinguish  tubercular  masses  from 
gummata. 


DISEASES  OF  THE  BRATN.  2 

4.  Carcinoma.  Primary  cancer  of  the  brain  occurs, 
but  usually  it  is  secondary,  developing  in  association 
with  malignant  growths  in  the  breast,  lung  and  pleura. 

Tumors  of  the  brain  of  rare  occurrence  include  lipoma, 
cystic  growths,  hydatids  and  psamoma. 

Clinical  History.  A  tumor,  wherever  situated  within  the 
cranium  and  independent  of  its  histological  character, 
gives  rise  to  general  symptoms,  chiefly  due  to  the  degree 
and  amount  of  compression  or  irritation  it  exerts  in  its 
immediate  vicinity  or  remote  parts  of  the  brain. 

General  symptoms.  Nearly  all  the  cephalic  symptoms 
of  brain  tumor  are  the  clinical  manifestations  of  crowding 
and  flattening  of  the  convolutions,  abnormal  tension  of 
the  dura  mater  and  circulatory  disturbance.  The  greater 
the  size  of  the  tumor  the  more  pronounced  and  nuliierous 
are  these  symptoms.  Besides,  intracranial  pressure  of 
the  venous  trunks  causes  ventricular  eff'usion. 

1.  Headache  is  the  earliest  and  most  constant  symp- 
tom. The  pain  is  generally  very  severe  and  marked  by 
exacerbations.  There  is  no  uniform  relation  between  the 
seat  of  the  pain  and  the  particular  location  of  the  tumor, 
but  in  persistent  occipital  headache  the  growth  has  often 
been  found  in  the  posterior  fossa.  Patients  evince  the 
violence  and  persistency  of  the  pain  by  groans  and  corru- 
gation of  the  brows  even  when  in  a  dazed  condition. 
They  are  sometimes  seen  to  grasp  the  head  with  the 
hands  and  run  to  and  fro  in  a  frantic  manner.  Sleep  is 
difficult  to  procure. 

2.  Vertigo  stands  next  in  prominence  as  an  early  symp- 
tom. The  dizziness  is  sometimes  so  aggravated  that 
patients  stagger  and  reel  as  if  they  were  drunk. 


2U  MA  X U A  L  O F  N ERVOUS  DISE A  SES. 

3.  Cerebral  vomiting  is  a  very  troublesome  and  intract- 
able symptom,  and  is  apt  to  come  on  as  soon  as  the 
patient  rises  from  bed. 

4.  Remarkable  slowness  of  the  pulse  is  frequently 
noticed.  Passive  congestion  of  the  cerebral  venous  trunks 
sometimes  brings  on  sudden  faintness  or  a  momentary 
attack  resembling  apoplexy. 

5.  A  marked  symptom  in  severe  cases  is  mental 
perturbation,  which  is  exhibited  in  the  expression  of 
the  face.  The  patient  appears  stupefied,  he  is  slow  in 
answering  questions  and  forgets  what  he  has  been  saying 
or  doing  a  moment  before. 

6.  Epileptiform  convulsions  occurring  in  brain  tumors 
may  be  grouped  among  the  general  symptoms,  but 
frequently  the  spasms  are  due  to  a  tumor  in  the  excitable 
motor  areas  of  the  cortex.  Partial  spasm  affecting  facial 
muscles  or  an  arm  also  indicates  the  existence  of  such  a 
definite  focal  lesion. 

7.  There  are  few  cases  of  cerebral  tumor  which  do  not 
develop  optic  neuritis.  This  is  a  symptom  of  pressure 
exerted  by  the  growth  wherever  located  in  the  brain.  It 
is  therefore  important  to  make  an  ophthalmoscopic  exam- 
ination when  a  cerebral  tumor  is  suspected  to  exist. 
Choked  disk  is  now  generally  supposed  to  be  caused  by 
the  cerebro-spinal  fluid  being  forced  into  the  lymph- 
sheath  of  the  optic  nerve.  Sight  may  be  unaffected  for  a 
long  time,  as  the  atrophy  of  the  disk  is  often  a  late  pro- 
cess. Amblyopia  tending  to  amaurosis  is  however  in 
some  cases  an  early  symptom  of  cerebral  tumor,  and  the 
oculist  may  be  the  first  to  discover  the  true  cause  of  the 
disturbed  vision. 


DISEASES  OF  THE  BRAIN.  245 

Focal  symptoms  of  cerebral  tumor.  A  brain  tumor  may 
during  its  whole  coarse  excite  no  other  but  general  symp- 
toms. Such  is  the  history  in  cases  where  the  tumor  is 
lodged  in  the  centrum  ovale  or  in  one  of  the  basal  gan- 
glia. It  is  also  a  peculiarity  of  cerebral  tumor  that 
symptoms  which  indicated  implication  of  definite  parts 
of  the  brain  may  disappear.  A  monoplegia,  or  even  a 
hemiplegia,  may  pass  away  and  not  return.  Such  an 
occurrence  is  explicable  on  the  supposition  that  a  change 
in  the  tumor  reduced  its  volume,  and  thus  the  pressure 
was  removed  from  the  particular  part  that  had  caused 
the  paralysis.  Aphasia  in  tumor  of  the  left  hemisphere 
may  in  this  manner  be  only  a  temporary  symptom. 
Partial  spasm  of  paralyzed  limbs,  which  is  rather  com- 
mon in  brain  tumor,  may  disappear  under  analogous 
circumstances. 

It  is  in  tumors  at  the  base  of  the  brain  that  special 
focal  symptoms  always  make  their  appearance.  A 
tumor  in  this  situation  affects  more  or  less  the  cranial 
nerves  where  they  emerge  from  the  brain.  The  paralysis 
of  these  nerves  shows  the  peripheral  type.  The  nerves 
which  are  subject  to  the  paralysis  include  the  different 
branches  of  the  motor  oculi,  the  trochlearis,  the  abducens, 
the  facial,  the  hypoglossal  and  the  trigeminus.  Each  of 
these  nerves  may  be  separately  affected  or  several  of 
them  are  simultaneously  paralyzed.  A  large  proportion 
of  cases  of  paralysis  of  one  or  more  of  these  cranial 
nerves,  where  the  existence  of  a  brain  tumor  is  suspected, 
result  from  syphilitic  gummata. 

To  describe  the  special  symptoms  significant  of  tumor 
in  other  parts  of  the  brain  would  merely  repeat  what  has 
already  been   stated  in  regard  to  the  pathological  diag- 


^J^ii  MA  N  UAL   OF  NER  VOUS   DISEASES, 

nosis  of  cerebral  lesions.  An  exception  might  be  made 
in  reference  to  cerebellar  tumor,  which  is  more  common 
in  children  than  adults.  The  general  symptoms  are 
sometimes  violent,  especially  the  constancy  of  the  pain 
in  the  occipital  region  and  the  incessancy  of  vomiting. 
Stiffness  of  the  neck  is  often  well  marked.  Choked  disk 
is  nearly  always  present.  Besides,  there  is  not  unfre- 
quently  unsteadiness  of  the  gait,  amblyopia,  anosmia 
and  deafness. 

Course.  At  autopsies  tumors  of  the  brain  have  been 
found  that  had  remained  entirely  dormant,  but  such 
instances  are  rare  exceptions.  Sometimes  a  cerebral 
tumor  abruptly  develops  symptoms  indicating  a  serious 
brain  trouble.  Usually  the  onset  is  slow,  and  the  disease 
runs  a  chronic  course  lasting  for  months  or  years.  The 
general  health  is  gradually  undermined  by  constant 
suffering  and  wakefulness.  Towards  the  close  amelio- 
ration is  brought  about  by  the  decline  of  the  mental 
activities  and  the  deepening  of  the  stupor.  A  fatal 
termination  sometimes  rapidly  ensues  from  a  succession 
of  epileptiform  convulsions. 

Diagnosis.  The  continuous  and  progressive  course  of 
cerebral  symptoms,  in  which  a  severe  headache  that 
appears  to  baffle  all  remedies  constitutes  a  prominent 
feature,  would  suggest  the  existence  of  a  cerebral  tumor- 
Such  a  diagnosis  is  greatly  strengthened  if  epileptiform 
convulsions  also  occur,  and  is  nearly  brought  to  a  cer- 
tainty if  choked  disk  is  discovered.  A  cerebral  abscess 
may  come  near  to  presenting  a  similar  set  of  symptoms, 
but  this  disease  can  often  be  traced  to  a  traumatic  or 
some  other  palpable  cause.  Its  duration  is  shorter  and 
choked  disk  is  much  less  frequently  found  than  in  tumor. 


DISEASES  OF  THE  BRAIN.  247 

The  implication  of  cranial  nerves  is  as  likely  to  be  due 
to  syphilitic  degeneration  as  to  a  sarcoma  at  the  base  of 
the  cranium.  The  differential  diagnosis  would  meet  here 
with  difficulties,  though  the  association  with  more  of  the 
general  symptoms,  and  especially  the  presence  of  choked 
disk,  would  tend  to  decide  in  favor  of  tumor.  Multiple 
sclerosis  may  possibly  imitate  brain  tumor,  but  the  for- 
mer is  the  more  chronic  disease  and  manifests  other 
symptoms  which  are  not  common  to  cerebral  tumor.  In 
very  rare  instances  a  chronic  hydrocephalus,  the  result 
of  a  circumscribed  meningitis,  has  been  found  that  dur- 
ing life  had  counterfited  a  brain  tumor.  In  children, 
who  are  frequently  subject  to  headache  and  convulsions, 
the  probable  existence  of  an  isolated  or  multiple  tuber- 
cule  should  be  taken  into  consideration. 

The  diagnosis  in  regard  to  the  character  of  a  cerebral 
tumor  is  sometimes  possible,  but  far  more  frequently  it  is 
impracticable.  A  predisposition  to  tubercular  infection 
in  children  would  influence  diagnosis  in  favor  of  a  tuber- 
cular tumor.  A  history  of  syphilis  would  do  the  same 
for  a  gumma.  The  existence  of  cancer  in  a  remote  part 
of  the  body  suggests  malignant  tumor  of  the  brain. 
Cerebral  aneurism,  which  seldom  causes  choked  disk,  is 
marked  by  paroxysms  of  violent  headache  and  frequent 
attacks  of  vomiting. 

Prognosis.  All  intracranial  tumors,  irrespective  of  their 
histological  nature,  tend  to  a  fatal  termination.  Excep- 
tion must  be  made  in  regard  to  syphihtic  gummata.  A 
guarded  opinion  is  advisable  as  to  the  duration  of  the 
disease,  though  two  years  is  about  the  utmost  limit. 
Death  may  happen  at  any  moment,  either  from  hemor- 
rhage or  epileptiform  convulsions. 


21,8  MA  X U A  L   OF  X E R  V OUS  DISEA  S ES . 

Treatment.  If  anything  is  to  be  expected  from  treatment 
in  cerebral  tumor  it  is  the  iodide  of  potassium  that  holds 
out  some  prospect  of  success.  This  remedy  is  not  only 
the  most  proper  and  efficacious  one  in  gummatous  intil- 
tration,  but  growths  of  a  different  nature  may  sometimes 
be  influenced  by  its  effects.  In  explanation  of  the  ben- 
efit sometimes  derived  from  the  remedy,  it  is  supposed 
that  tumors  often  give  rise  to  symptoms  not  so  much 
dependent  upon  their  size  and  location  as  upon  the  inflam- 
matory softening  and  oedema  they  produce. 

There  remains  still  much  scope  for  s3niiptomatic  treat- 
ment. Anodynes  for  the  relief  of  pain  are  indispensable. 
The  bromides  exert  some  control  over  the  convulsive 
paroxysms.  Alcoholic  stimulants,  tea  and  coffee  should 
be  strictly  prohibited. 

ACUTE  AND  CHRONIC  ABSCESS  OF  THE  BRAIN. 

(Encephalitis,  j 

Etiology.  I.  'Traumatism  of  the  skull  is  one  of  the  chief 
causes  of  cerebral  abscess.  Complicated  fractures  that 
destroy  brain  tissue  and  permit  the  ingress  of  infectious 
materials  invariably  give  rise  to  collections  of  pus  within 
the  cranium.  It  is  equally  a  iviatter  of  experience  that 
cerebral  abscesses  may  develop  from  contusion  and  lacer- 
ation of  the  scalp,  although  the  skull  is  uninjured.  Cases 
of  this  kind  usually  come  first  under  the  notice  of  the 
general  practitioner,  for  the  extension  of  the  inflamma- 
tion through  the  bones  is  often  a  late  process.  2.  Disease 
of  the  petrous  portion  of  the  temporal  bone  originating 
from  inflammation  of  the  middle  ear  is  next  in  the  order 
of  frequency  a  cause  of  cerebral  abscees.     Children  and 


DISEASES   OF  THE  BRAIN.  3^9 

youths  who  have  runninor  ears  are  in  constant  danger  of 
being  either  suddenly  attacked  with  acute  cerebral  abscess 
or  meningitis.  The  abscess  in  this  class  of  cases  is 
situated  in  the  parietal  lobe,  or  in  one  of  the  hemispheres 
of  the  cerebellum,  and  is  usually  associated  with  suppur- 
ative phlebitis  of  a  sinus.  3.  The  metastatic  abscess  is 
generally  multiple  and  of  small  size.  It  develops  dur- 
ing the  course  of  pyaemia  and  is  of  subordinate  clinical 
importance.  Abscesses  of  this  character  sometimes  form 
in  purulent  bronchitis.  There  still  remains  a  class  of 
cerebral  abscess  for  which  no  cause  can  be  assigned. 

Anatomical  Changes.  A  cerebral  abscess  may  merely  pre- 
sent the  appearance  of  a  small  spot  of  softening.  If  there 
is  only  one  it  is  generally  of  a  large  size.  The  greater 
part  of  a  hemisphere  is  sometimes  found  transformed  into 
a  collection  of  pus.  The  pus  is  of  a  greenish-yellow  color 
or  reddish  from  -the  mixture  of  blood  globules.  It  may 
be  odorless  or  offensive  and  consist  of  the  remnants  of 
destroyed  nerve  tissue.  The  cavity  in  which  it  is  lodged 
presents  irregular  walls.  The  surrounding  parenchyma 
of  the  brain,  to  a  greater  or  less  distance,  is  softened  and 
infiltrated  with  an  abundance  of  granular  corpuscles.  A 
large  abscess  near  the  surface  of  the  brain  may  sometimes 
be  recognized  by  fl actuation.  When  centrally  located  it 
not  unfrequently  bursts  into  a  ventricle. 

A  cerebral  abscess  of  old  date  is  usually  found  encap- 
sulated. The  cyst-wall  is  formed  of  fibro-cellular  tissue. 
Its  inner  layer  consists  of  a  smooth  pyogenic  membrane. 
The  contents  of  a  chronic  abscess  often  resemble  a  thick- 
ened cheesy  substance. 

Clinical  History.  An  acute  cerebral  abscess,  whether 
directly  caused    by   an  injury  or  any  other  cause,  which 


S50  MA  NUAL   0  F  NER  V  OUS  DI S  EA  SES . 

after  a  period  of  latency  suddenly  kindles  into  activity, 
gives  rise  to  symptoms  that  cannot  be  distinguished  from 
those  of  acute  meningitis.  There  is  a  high  grade  of 
febrile  excitement  preceded  by  a  chill  or  rigor,  a  violent 
or  deep,  dull  pain  of  the  head,  delirium  and  finally 
stupor  and  coma.  Rarely  does  an  acute  cerebral  abscess 
run  into  the  chronic  stage.  Precisely  the  same  group  of 
symptoms  of  a  fatal  tendency  attends  the  class  of  encap- 
sulated abscess,  which  either  rupture  into  a  ventricle  or 
escape  to  the  surface  of  the  brain. 

The  clinical  history  of  chronic  abscess  is  marked  by  a 
course  of  symptoms  of  much  less  severity.  There  are 
often  attacks  of  violent  headache,  probably  brought  on  by 
incidental  exciting  causes  that  disturb  the  cerebral  circu- 
lation, and  is  attended  by  the  irregular  occurrence  of 
chills.  Nausea  is  sometimes  a  troublesome  symptoi^i  that 
often  terminates  in  vomiting.  The  general  symptoms  in 
many  cases  may  amount  to  a  feeling  of  ill  health,  nervous 
weakness  and  a  gradual  emaciation.  But  the  persistence 
of  pain  in  the  head,  the  recurrence  of  febrile  disturbance, 
occasional  delirium,  the  sudden  attack  of  convulsions  and 
a  deepening  stupor  tell  the  gravity  of  the  underlying 
disease. 

The  focal  symptoms  vary  with  the  location  of  the  abscess- 
An  abscess  rarely  occupies  the  basal  region  of  the  brain 
and  hence  the  cranial  nerves  in  that  situation  are  seldom 
affected.  A  large  abscess  in  the  frontal  lobe  may  give 
rise  to  no  special  symptoms  at  all  if  it  does  not  involve 
the  central  convolutions.  But  an  abscess  in  the  latter 
region  of  the  brain  is  very  likely  to  cause  monoplegia  or 
hemiplegia,  often  attended  by  epileptiform  spasms.  The 
appearance    of  paralysis    affecting   the    motor   oculi,  the 


DISEASES  OF  THE  BRAIN  .  251 

hypoglossiis  or  facial  nerve,  shows  the  encroachment  of 
the  abscess  toward  the  base  of  the  brain.  Hemianospia  if 
sought  for  will  probably  be  discovered  if  the  abscess 
occupies  the  frontal  fossa.  Paraphasia  has  been  observed 
in  abscess  of  the  temporal  lobe. 

The  duration  of  chronic  cerebral  abscess  varies.  Recov- 
ery is  of  exceptional  occurrence.  The  fatal  termination 
may  slowly  ensue  from  aggravation  of  the  general  symp- 
toms. It  rapidly  takes  place  when  changes  in  the  abscess 
develop  the  symptoms  of  acute  meningitis. 

Diagnosis.  Cerebral  abscess  admits  of  being  diagnosed 
with  considerable  certainty  when  cephalic  symptoms  of  a 
general  character  are  traceable  to  a  previous  injury  to  the 
skull,  or  are  associated  with  disease  of  the  ear  or  the 
upper  nasal  cavity.  The  differential  diagnosis  between 
cerebral  abscess  and  tumor  is  not  always  easy.  The  etiol- 
ogy of  the  individual  case  affords  the  most  reliable 
information.  Choked  disk  is  far  less  common  in  abscess 
than  tumor.  Febrile  excitement,  especially  repeated 
chills,  speak  in  favor  of  abscess.  The  sudden  occurrence 
of  violent  head  symptoms  that  indicates  a  very  grave 
brain  trouble  suggest  abscess. 

Treatment.  Since  the  introduction  of  systematic  anti-sep- 
tic treatment,  surgeons  are  emboldened  to  trephine  the 
skull  to  evacuate  an  abscess.  Whenever  such  an  opera- 
tion is  feasible  it  holds  out  the  only  prospect  of  relief. 
But  a  procedure  of  this  kind  is  often  impracticable  in 
view  of  the  difficulty  of  locating  the  abscess  with  sufficient 
precision,  or  to  reach  it  with  safety  to  the  patient- 
Nothing  else  is  left  when  an  operation  is  not  justifiable 
than  symptomatic  treatment.  Leeches  and  cold  to  the 
head  serve  to  calm  the  cerebral  excitement.     The  chief 


S.5£  MA  X UA  L   OF  XEB  V 0  US  DISEA  S ES . 

remedies  to  allay  the  headache  and   spasms  are  morphia 
and  chloroform  inhalations. 

CEREBRAL  SYPHILIS. 

Etiology.  Syphilis  involves  the  nervous  system  at  a  late 
period,  usually  when  the  outward  evidences  of  the  con- 
stitutional disease  have  disappeared.  It  is  prohably 
owing  to  an  exciting  cause  or  predisposition  to  nervous 
affections  that  leads  to  the  development  of  cerebral 
syphilis. 

Anatomical  Changes.  Two  varieties  of  gummy  tumors  are 
recognized,  though  they  frequently  occur  in  combination. 
1.  The  circumscribed  syphilitic  tumor  consists  of  a  dense 
cheesy  mass  of  a  yellowish  color.  Histologically  it  is 
a  granular  tissue  more  or  less  vascular.  The  gumma 
generally  originates  in  the  dura  mater  and  sometimes  in 
the  substance  of  the  brain.  In  the  latter  situation  it  is 
difficult  to  distinguish  svphilitic  granulations  from  tuber- 
cles. 2.  The  second  variety  consists  of  a  soft  grayish 
mass,  irregular  in  outline  and  blending  with  the  surround- 
ing healthy  tissue.  It  is  made  up  of  granular  ceils  and  is 
very  vascular.  This  syphilitic  infiltration  is  sometimes 
transformed  into  fine  cicatrical  tissue. 

Much  importance  attaches  to  the  specific  changes  which 
the  walls  of  cerebral  blood-vessels  undergo.  Branches  of 
the  middle  cerebral  and  posterior  cerebral  arteries  are 
particularly  prone  to  be  attacked.  The  vascular  walls 
become  opaque  and  gradual Iv  assume  a  whitish  color. 
Spots  of  a  dense  consistence  form  in  jDortions  of  the  vessels 
and  gradually-  change  them  into  a  uniform  cartilaginous 
hardness.  This  change  begins  as  an  endarteritis  and 
finally   causes  obliteration  of  the  vessels  througli  the  for- 


DIS  EASES   OF   THE  BRAl  N.  353 

mation  of  thrombi  which  arrest  the  circulation  in  certain 
areas  of  the  brain.  The  diseased  arteries  on  yielding  to 
the  blood  pressure  niay  rupture  and  produce  hemorrhage. 

Clinical  History.  Precursory  symptoms,  though  not  char- 
acteristic of  the  specific  causation,  often  make  their 
appearance  during  a  considerable  lei. gth  of  time  before 
the  complete  development  of  the  grave  forms  of  cerebral 
syphilis.  The  cephalic  symptoms  of  this  order  include 
headache,  vertigo,  insomnia,  neuralgiform  pains  of  the 
head  and  face  (worse  at  night)  and  occasionally  slight 
mental  impairment.  The  occurrence  of  paralysis  affect- 
ing cranial  nerves  is  of  greater  diagnostic  significance. 
Some  of  the  ocular  muscles  are  especially  prone  to  be 
involved.  Ptosis  has  become  notorious  as  a  sign  of 
syphilis.  The  facial  nerve  is  quite  often  paralyzed  and 
next  in  frequency,  the  sixth. 

The  onset  of  cerebral  syphilis  is  often  announced  by  a 
sudden  epileptiform  seizure  or  an  apoplectiform  attack, 
followed  by  hemiplegia.  In  other  cases  the  initial  symp- 
tom is  a  marked  somnolence  or  a  peculiar  obtuseness  of 
the  intelligence. 

Severe  implication  of  the  higher  nerve  centers  are  fre- 
quently witnessed  during  the  whole  course  of  the  disease 
and  may  at  any  time  lead  to  a  fatal  termination.  It  is 
remarkable,  however,  how  often  the  grave  symptoms  of 
cerebral  syphilis  disappear  without  being  succeeded  by 
serious  consequences,  especially  if  a  prompt  and  energetic 
treatment  be  adopted. 

One  of  the  marked  types  of  cerebral  syphilis  presents  a 
group  of  symptoms  characteristic  of  brain  tumor.  It  is 
not  necessary  to  go  over  the  same  ground  again  in  refer- 
ence to  this  subject.     General  and  focal  symptoms,  as  has 


25 Jf  MA  N  UA  L   OF  NERVOUS  DISEASES. 

already  been  mentioned,  characterize  a  brain  tumor  irre- 
spective of  its  etiology  and  histological  structure.  The 
only  point  in  this  connection  which  is  of  practical  impor- 
tance is  the  circumstance  that  the  favorite  situation  of  a 
gummatous  tumor  is  the  basilar  region  of  the  brain,  where 
the  cranial  nerves  are  exceedingly  prone  to  be  involved. 

Another  type  of  cerebral  syphilis  simulates  the  clinical 
features  of  the  "general  paresis  of  the  insane,"  though 
the  pathological  changes  are  not  extensive.  Occasionally 
syphilis  of  the  brain  appears  under  the  guise  of  multiple 
sclerosis. 

Diagnosis.  The  chief  reliance  in  diagnosis  of  cerebral 
syphilis  rests  on  the  previous  history  of  the  patient.  An 
accurate  search  for  the  objective  symptoms  of  the  vene- 
real disease  is  all  the  more  necessary  as  its  characteristic 
signs,  when  the  nervous  system  is  affected,  are  usually 
not  apparent.  None  of  the  cerebral  symptoms  dependent 
on  syphilis  are  reliable  guides  of  diagnosis.  More  infor- 
mation is  furnished  by  the  order  of  occurrence  of  the 
several  symptoms,  their  peculiar  grouping,  the  presence 
of  isolated  forms  of  paralysis  and  their  irregular  combi- 
nations. It  is  not  usual  to  encounter  the  sequence  and 
assemblage  of  symptoms  peculiar  to  cerebral  syphilis  in 
ordinary  gross  lesions  of  the  brain.  The  age  of  the 
patient  is  of  some  diagnostic  importance.  An  apoplectic 
attack  or  hemiplegia  in  a  young  person,  if  embolism,  due 
to  valvular  disease  of  the  heart,  can  be  excluded,  is  more 
likely  owing  to  syphilitic  endarteritis  than  to  ordinary 
cerebral  hemorrhage. 

Prognosis  and  Treatment.  Of  all  the  grave  affections  of  the 
nervous  system  those  of  a  syphilitic  origin  afford  rela- 
tively the  most  favorable  prognosis.     Permanent  destroy- 


DISEASES   OF  THE  BRAIN.  255 

ing  lesions,  due  to  the  effects  of  the  venereal  poison,  are 
of  course  as  little  amenable  to  curative  treatment  as 
those  from  any  other  cause.  But  even  in  very  unpromis- 
ing cases  some  measure  of  improvement  is  often  attain- 
able if  the  specific  treatment  is  followed  up  with  prompt- 
ness and  perseverance.  The  only  questiori  that  can  arise 
in  relation  to  the  treatment  refers  to  the  choice  of  the 
anti-syphilitic  remedies,  n:5ercury  or  iodide  of  potassium. 
Mercurial  inunction  is  decidedly  the  quickest  and  safest 
way  to  bring  the  system  under  the  influence  of  the  spe- 
cific, though  this  method  is  better  adapted  for  hospital 
than  private  practice.  The  continuation  of  the  inunction 
must  be  governed  by  the  efl'ects  that  follow.  The  potass, 
iod.  is  advantageously  employed  at  the  same  time.  This 
remedy  alone  often  suffices,  but  it  must  be  given  in  large 
doses  and  for  a  long  time.  Hutchinson's  plan  of  using 
the  mercury  with  chalk  is  a  good  one  when  inunction  is 
objectionable. 


CHAPTER  XIV. 

MULTIPLE  SCLEROSIS  OF  THE  BRAIX  AM) 
SPINAL  ( ORD. 

(Disseminated  Sclerosis.     Sclerose  ex-plaque.; 

Etiology.  Multiple  sclerosis  was  formerly  confounded 
with  different  forms  of  disease  effecting  the  nervous 
system.  We  are  indebted  to  the  French  school  of  neu- 
rologists for  an  accurate  description  of  its  symptoms. 
A  hereditary  influence  is  evident  in  some  cases.  The 
disease  is  most  frequently  seen  in  young  persons 
between  the  ages  of  20  and  35  years,  but  it  has 
also  been  observed  in  children  under  10  years.  It 
occurs  oftener  in  the  female  than  the  male  sex.  The 
isupposed  exciting  causes  are  exposure,  physical  over- 
exertion  and  emotional  disturbances. 

Clinical  History.  In  consequence  of  the  very  gradual 
development  of  the  disease,  no  conspicuous  symptoms 
make  their  appearance  in  the  early  stage,  but  a  very 
marked  group  of  symptoms   characterizes  typical  cases. 

A  peculiar  tremor  constitutes  the  most  prominent 
symptom.  It  is  owing  to  thi«'  symptom  that  the  disease 
was  formerly  confounded  with  paralysis  agitans.  But 
the  trembling  in  sclerosis  is  only  excited  when  the  patient 

(2.%) 


M  VLTIPL  E  S  C  L  EROS  IS.  257 

attempts  to  carry  out  a  movement.  As  soon  as  he 
relinquishes  the  effort,  the  trembling  ceases.  The  tremor 
in  paralysis  agitans  is  of  a  more  limited  sweep,  and  is 
continuous  whether  the  patient  is  at  rest,  or  in  motion. 
In  sclerosis  no  tremor  is  observed,  as  long  as  the  patient 
is  quiet.  When  he  rises  frojii  his  seat,  or  moves  a  limb 
the  trembling  begins.  When  grasping  a  glass  of  water  to 
bring  it  to  the  lips,  the  arm  shakes  violently,  the  hand 
takes  a  wide  excursion  and  the  water  is  spilt.  If  the 
glass  reaches  the  mouth,  it  clatters  against  the  teeth, 

A  singular  defect  of  speech,  analogous  to  the  tremor  is 
another  conspicuous  symptom  of  sclerosis.  Words  are 
pronounced  in  a  hesitating,  drawling  manner,  a  pause 
being  made  between  each  word  or  syllable,  as  in  scanning. 
The  voice  is  monotonous  and  a  tremulous  movement  of 
the  lips  and  tongue  is  observed  during  speech. 

Nystagmus  is  noticed  in  about  half  the  cases.  The 
eyelids  oscillate  in  a  lateral  direction,  especially  when  the 
patient  is  intent  on  looking  at  a  remote  object. 

The  normal  muscular  power  is  often  well  preserved  for 
a  long  time,  but  paresis  of  the  limbs  is  sometimes  an 
early  symptom  and  may  terminate  in  complete  paralysis. 
A  spastic  condition  of  the  muscles  is  a  far  more  constant 
and  conspicuous  symptom.  This  motor  disturbance  is 
chiefly  due  to  exaggeration  of  the  tendon  reflexes.  It 
causes  stiffness  of  the  limbs,  and  when  associated  with 
considerable  paresis  that  peculiar  gait  is  witnessed  which 
is  characteristic  of  spastic  spinal  paralysis.  At  a  late 
stage,  walking  is  quite  impossible.  Permanent  contract- 
ures develop  in  the  lower  extremities,  so  that  in  well 
marked  cases,  the  heels  touch  the  nates,  and  the  thighs 
are  firmly  flexed  on  the  trunk. 

17 


258  MA  X  UAL   OF  NER  VO  US  DIS  EA  S  ES . 

Disorders  of  sensibility  are  insignificant  or  entirely 
absent.  Sometimes  there  is  slight  bluntness  of  the  skin, 
but  anaesthesia  is  of  the  rarest  occurrence.  The  cuta- 
neous reflexes  are  normal. 

Ocular  symptoms  are  only  occasionally  present.  A 
serious  complication  is  the  development  of  optic  neuritis 
terminating  in  atrophy  of  the  disk. 

The  functions  of  the  bladder,  the  rectum  and  sexual 
organs  are  not  disturbed  in  a  typical  case. 

Cerebral  symptoms  sometimes  arise  during  the  course 
of  the  disease.  Patients  begin  to  exhibit  mental  weak- 
ness, and  often  break  out  into  fits  of  sobbing  without  an 
assignable  cause.  Headache  and  vertigo  are  frequently 
complained  of  in  the  early  stage. 

Anatomical  Changes.  According  to  Leyden,  the  patho- 
logical process  of  multiple  sclerosis  is  of  the  nature  of 
an  interstitial  chronic  myelitis,  which  at  first  affects  the 
neuroglia  and  afterwards  involves  the  nerve  elements. 
Rindfleisch  believes  that  the  anatomical  change  begins 
in  the  blood-vessels  and  secondarily  implicates  the  ner- 
vous tissue.  Tire  nodules  are  recognized  as  hard  yellow- 
ish patches  scattered  through  different  portions  of  the 
brain  and  cord,  and  chiefly  occupy  the  surface  of  these 
structures.  They  are  found  in  great  abundance  in  the 
spinal  cord  and  pons,  and  are  less  numerous  in  the 
medulla,  the  cerebellum  and  the  central  ganglia.  The  nod- 
ules, when  examined  with  the  microscope,  are  seen  to 
consist  of  reticulated  connective  tissue  in  which  a  few 
nerve  fibres  are  still  visible.  The  coats  of  the  blood- 
vessels are  thickened.  The  neuroglia  is  changed  into  a 
dense  fibrous  tissue  which  surrounds  and  compresses  the 


MULTIPLE  SCLEROSIS.  250 

remaining  nerve  fibres,  but  their  axis  cylinders  are  pre- 
served for  a  long  time. 

Atypical  cases  of  Sclerosis.  A  certain  number  of  cases 
come  under  notice  which  deviate  in  their  symptoma- 
tology from  the  typical  form  of  sclerosis.  It  has  often 
happened  that  patients  presented  symptoms,  that  gave 
no  intimation  of  the  existence  of  sclerosis,  but  which 
post-mortem  examination  showed  to  have  been  due  to 
this  pathological  condition.  The  reason  of  this  anomaly 
is  the  localization  of  the  sclerosed  patches  in  special 
parts  of  the  nerve  centers,  which  would  naturally  give 
prominence  to  corresponding  symptoms.  It  will  suffice 
to  give  a  brief  summary  of  these  atypical  cases  of  the 
disease. 

1.  Cases  resembling  loco-motor  ataxia,  in  which  the 
nodules  invade  the  posterior  columns  of  the  cord. 

2.  Apoplectiform  attacks  followed  by  hemiplegia,  and 
epileptiform  convulsions.  In  these  cases  the  nodules  pre- 
ponderate in  the  brain. 

3.  The  symptoms  of  chronic  transverse  myelitis,  includ- 
ing paraplegia,  anaesthesia  and  implication  of  the  sphinc- 
ters of  the  bladder  and  rectum.  Here  the  patches  involve 
the  thickness  of  the  cord. 

4.  Nodules  situated  in  the  lateral  columns  of  the  cord 
give  rise  to  spastic  spinal  paralysis.  Multiple  sclerosis 
in  combination  with  muscular  atrophy  indicates  the 
extension  of  the  lesion  to  the  anterior  gray  cornua  and 
the  picture  of  amyotrophic  lateral  sclerosis  is  presented. 
Implication  of  the  medulla  oblongata  gives  rise  to  symp- 
toms of  bulbar  paralysis. 

Diagnosis.  A  typical  case  of  multiple  sclerosis  offers 
no  difficulty  to  diagnosis,  if  the  peculiar  combination  of 


260  MANUAL   OF  NERVOUS  DISEASES. 

symptoms  characteristic  of  the  disease  is  borne  in  mind. 
Atypical  cases  are  certainly  embarrassing,  but  the  very 
medley  of  symptoms  showing  functunal  disturbance  of 
different  parts  of  the  nervous  system  is  suggestive  of 
multiple  sclerosis. 

Prognosis.  The  only  encouraging  features  in  the  prog- 
nosis of  multiple  sclerosis  are  the  occasional  pauses  and 
periods  of  improvement  during  the  course  of  the  disease. 
There  are  no  reliable  reports  of  recovery. 

Treatment.  Therapeutics  must  be  contented  with  efforts 
to  improve  some  of  the  symptoms.  Temporary  benefit 
may  be  expected  from  electrical  treatment.  Remedies 
which  are  useful  in  chronic  myelitis  are  indicated. 

PARALYSIS   AGITANS. 

(Shaking  Palsy.) 

Etiology.  Paralysis  agitans  is  a  disorder  of  advanced 
life,  although  it  is  occasionally  seen  in  young  people.  A 
hereditary  influence  is  not  very  evident.  Persons,  who 
have  passed  through  much  hardship  in  life  are  consid- 
ered especially  liable  to  be  affected.  An  affection  resem- 
bling paralysis  agitans  is  sometimes  seen  to  develop  after 
injuries  and  acute  febrile  diseases. 

Clinical  History.  The  essential  symptoms  of  paralysis 
agitans  include  tremor  and  stiffness  of  muscles.  Tremor 
is  the  earlier  symptom.  It  usually  begins  in  one  hand 
and  gradually  becomes  general.  The  patient  is,  at  the 
commencement,  able  to  control  the  shaking  by  a  strong 
voluntary  effort  or  by  leaning  his  body  against  a  support. 
Mental  excitement  increases  the  trembling,  but  active 
exertion  appears  to  diminish  it.  The  tremor  ceases  during 


PABA  L  YS  IS  A  G  IT  A  XS .  261 

sleep.  It  may  for  a  considerable  length  of  time  be  con- 
fined to  one  arm  or  one  side  of  the  body,  and  when  gen- 
eral it  is  always  most  apparent  in  the  hands.  On  closely 
observing  the  involuntary  movements  of  the  hand,  it  is 
noticed  that  the  thumb  closes  on  the  fingers  (as  in  spin- 
ning wool  or  rolling  pills.)  The  head  is  the  least  afi'ected, 
and  often  not  at  all.     Speech  is  slow  and  jerky. 

Stiff'ness  of  the  muscles  is  a  very  conspicuous  symptom, 
and  is  the  chief  cause  of  the  motor  weakness.  A  fixidness 
of  the  facial  muscles  gives  a  stolid  expression  to  the 
features.  There  is  a  perceptible  interference  with  the  act 
of  swallowing,  which  is  probably  caused  by  muscular 
rigidity  rather  than  by  the  tremor.  The  fixed  condition 
of  the  muscles  in  advanced  cases,  causes  much  difficulty 
in  standing  and  walking,  although  the  gross-muscular 
power  is  little  impaired.  The  patient  requires  assistance 
to  raise  himself  from  the  recumbent  position.  He  is 
unable  in  bed  to  turn  from  one  side  to  the  other.  He 
has  to  make  an  extra  effort  to  rise  from  his  seat,  though 
when  he  is  once  on  his  legs  he  may  still  manage  to  walk 
well  enough  :  but  as  the  disease  progresses  he  needs  the 
aid  of  a  stick  to  steady  himself.  At  every  step  the  body 
sags  forward,  and  the  patient  is  unable  without  help  to 
regain  the  perpendicular,  he  is  therefore  compelled  to 
quicken  his  gait  more  and  more  in  order  to  avoid  falling 
forward  upon  the  face.  He  is  thus  forced  into  a  run, 
which  he  cannot  stop  until  he  meets  with  some  object 
that  offers  him  a  support.  If  he  is  still  able  to  keep  at  a 
walk  he  makes  the  impression  of  continually  seeking  his 
center  of  gravity.  This  phenomenon  is  called  "propul- 
sion." Sometimes  the  patient  has  a  tendency  to  run 
backward  (retropulsion.)     Such  individuals  are  usually 


262  M  A  X UA  L   OF  XER  V 0  US  BIS EA  S ES . 

seen  to  walk  with  the  arms  crossed  behind  the  back;  the 
object  being  to  counterbalance  the  sagging  forward  of  the 
body. 

In  well-marked  cases  of  paralysis  agitans  a  peculiar 
alteration  in  the  attitude  of  the  body  develops  which  is 
typical  of  the  disease,  and  by  which  it  can  be  recognized 
in  those  exceptional  cases  where  the  trembling  is  insigni- 
ficant or  entirely  absent.  The  stiffness  has  not  only 
invaded  the  trunk,  but  also  the  muscles  of  the  neck  and 
some  of  the  flexors  and  extensors  of  the  arms  and 
lingers.  The  head  strongly  bends  forward,  the  trunk  is 
inclined  in  the  same  direction;  the  upper  arms  are  closely 
held  to  the  side  of  the  chest,  the  forearms  are  somewhat 
flexed  so  that  the  elbows  stand  off  from  the  body,  and 
the  position  of  the  fingers  resemble  that  assuUiCd  in 
holding  ii  pen.  In  rigidity  of  the  lower  extremities  the 
legs  are  slightly  flexed  on  the  trunk,  the  knees  are  turned 
inwards  and  the  heels  are  somewhat  raised.  In  the  con- 
dition of  advanced  muscular  stiffness,  the  patient  moves 
as  if  all  the  joints  had  lost  their  mobility. 

ir.  the  commencement  of  the  disease,  patients  some- 
times complain  of  rheumatic-like  pains  especially  in  the 
shoulder.  A  subjective  feeling  of  internal  heat,  is  more 
common,  though  the  thermometer  shows  no  elevation  of 
temperature.  Frequently  a  profuse  perspiration  breaks 
out.  Other  incidental  symptoms  may  develop  during  the 
course  of  the  disease.  Paralysis  agitans  often  comes  to  a 
standstill,  so  that  it  may  last  for  many  years,  but  recov- 
eries are  exceptional. 

Pathology.  As  paralysis  agitans  usually  occurs  in  aged 
persons,  it  has  been  conjectured  that  senile  decay  may 
be   the   true   cause   of    the   disease.      But    post-mortem 


CHOREA.  263 

examinations  show  no  distinctive  changes  of  the  nervo- 
muscular  apparatus.  Probably  the  finer  anatomical 
changes  that  exist  escape  our  methods  of  investigation. 

Diagnosis.  The  recognition  of  a  typical  case  of  paral- 
ysis agitans  is  easy.  In  the  foregoing  section  the  dis- 
tinction from  the  tremor  of  multiple  sclerosis  has  been 
pointed  out.  Senile  trembling  is  less  marked  and  of  more 
limited  extent  than  the  tremor  of  paralysis  agitans,  and 
is  not  attended  by  muscular  stiffness  and  paresis. 

Treatment.  It  would  be  unprofitable  to  enumerate  the 
various  remedies  that  have  been  tried  in  this  disease.  In 
the  early  stage  it  may  be  possible  to  control  the  tremor. 
The  prolonged  employment  of  the  subcarbonate  of  iron 
in  large  doses  appeared  to  have  been  useful  in  a  case 
reported  by  Dr.  Elliotson.  Charcot  saw  benefit  from 
hyosciamine.  Reynolds  observed  mitigation  of  the  tremor 
from  the  wearing  of  a  Pulvermacher  chain.  Beneficial 
effects  are  claimed  for  arsenic.  Galvanism  is  sometimes 
of  service  in  mild  cases. 

CHOREA. 

(St.  Vitus'  Daxce.) 

Etiology.  Chorea  is  most  frequently  observed  to  attack 
children  between  the  periods  of  the  second  dentition 
and  puberty.  It  predominates  in  the  female  sex.  A 
direct  hereditary  transmission  cannot  be  shown  to  exist, 
but  it  may  be  assumed  that  a  constitutional  susceptibility 
predisposes  to  its  development.  Psychical  disturbances, 
especially  fright,  act  as  exciting  causes  in  many  cases. 
A  similar  mental  influence  operates  in  those  singular 
cases  resulting  from  imitation.  Chorea  often  appears 
during  the  pregnancy  of  primipara?.    The  disease  is  prob- 


2G4  M  A X UA  L  0 F  X ERVO  U S  DIS EA  SES . 

ably  of  a  reflex  character  when  induced  by  intestinal 
irritation,  especially  from  worms.  A  causal  relation 
appears  to  exist  between  chorea  and  rheumatism;  or  at 
least  chorea  sometimes  co-exists  with  valvular  disease  of 
the  heart  which  had  been  preceded  by  slight  rheumatic 
symptoms. 

Clinical  History.  The  initial  symptoms  of  chorea  are 
usually  misunderstood  by  parents  and  teachers.  The 
affected  children  are  often  chided  and  even  punished  for 
having  contracted  certain  objectionable  habits  and  for 
indulging  in  silly  behavior.  These  little  patients  let 
things  drop  from  their  hands,  make  all  kinds  of  grimaces, 
continually  shrug  their  shoulders,  scribble  when  required 
to  write  and  exhibit  a  constant  restlessness.  Very  soon, 
however,  these  irregular  movements  and  contortions  are 
observed  to  be  involuntary  and  to  become  general  and 
aggravated  as  the  disease  advances.  Volitional  move- 
ments always  start  the  jerks,  but  they  also  come  on 
spontaneously.  The  motor  disturbance  may  make  long 
pauses  when  the  patient  is  quiet,  but  in  many  cases  they 
are  continuous  or  appear  in  rapid  succession.  In  severe 
cases,  the  whole  body  wriggles  and  assumes,  with  short 
respites,  grotesque  attitudes.  Xearly  every  voluntary 
muscle  may  show  incoordinate  movements.  If  the  facial 
muscles  are  afi'ected,  the  brow  wrinkles  and  the  mouth 
is  distorted.  There  is  occasional  winking  of  the  eye-lids. 
The  pupils  are  usually  dilated.  The  tongue  is  suddenly 
thrust  forward  and  as  suddenly  withdrawn.  Speech 
becomes  affected,  swallowing  is  interrupted,  strange 
sounds  are  produced  by  spasmodic  action  of  the  laryn- 
geal muscles  and  the  respiration  is  often  irregular. 


CHOREA.  265 

The  choreic  movements  generally  begin  in  the  upper 
limbs  and  are  there  most  prominent.  The  arms  are 
flexed,  extended,  twisted  and  thrown  about  in  every 
possible  direction.  The  lower  extremities  are  much  less 
afl'ected,  but  now  and  then  one  leg  is  thrown  forward  or 
sideways,  or  the  knees  suddenly  bend  as  if  the  patient 
was  about  to  fall.  In  some  cases  the  trunk  is  also 
involved,  so  that  the  body  leans  for  a  moment  to  one  side 
or  is  doubled  up. 

When  the  disorder  is  of  a  violent  character  it  renders 
the  patient  completely  helpless.  He  is  unable  to  keep  on 
his  feet,  and  must  be  fed  and  dressed.  The  constant 
friction  of  the  elbows  and  the  knees  against  hard  sub- 
stances produces  abraisons  of  the  skin.  The  tossing  and 
jerking  may  be  so  violent  that  the  patient  has  to  be  fast- 
ened down  in  bed.  There  is,  however,  every  conceiv- 
able grade  of  intensity  of  the  disease.  Some  patients  when 
they  are  quiet  and  attention  is  not  directed  to  their  move- 
ments appear  to  be  but  slightly  affected.  Choreic  move- 
ments cease  during  sleep.  In  hemichorea,  as  the  name 
imports,  the  motor  disturbance  is  unilateral.  It  is 
remarkable  that  choreic  patients  never  complain  of 
fatigue  caused  by  the  incessant  jactitations. 

Increase  of  sensibility  is  sometimes  noticed  at  the 
outset  of  the  disorder,  and  later  in  its  course  a  slight 
paresis  and  mental  obtuseness  may  be  observed  in  a  few 
cases.  Endocardiac  murmur  in  connection  with  chorea 
is  not  always  a  sign  of  heart  disease  for  the  murmur 
may  be  merely  a  choreic  symptom.  The  reflexes  rarely 
show  any  alteration.  The  temperature  is  not  elevated 
however  severe  the  muscular  contractions  may  be. 


266  MA  N  UAL  OF  NER  VO  US  DISEASES, 

The  termination  is  variable.  Mild  cases  may  subside 
in  four  or  six  weeks.  The  average  duration  of  an  attack 
is  about  three  months,  but  sometimes  the  disorder  is  pro- 
tracted for  a  year  or  more. 

Pathology.  Post-mortem  examinations  have  thus  far  led 
no  satisfactory  explanation  of  the  nature  of  chorea.  There 
is  hardly  a  doubt  that  some  motor  center  is  involved, 
but  which  part  of  the  nervous  system  is  affected,  or  what 
the  character  of  the  pathological  condition  may  be  is 
undetermined.  Chorea  must  therefore  be  provisionally 
considered  to  come  under  the  category  of  the  neuroses. 
Foyers  of  softening,  probably  due  to  capillary  embolism 
are  occasionally  found  in  the  basal  ganglia,  but  it  is  far 
from  certain  that  these  anatomical  changes  have  any 
relation  with  true  chorea. 

A  cerebral  origin  of  the  disease  may  be  inferred  from 
the  occurrence  of  hemichorea  and  mental  weakness. 

Diagnosis.  It  is  hardly  possible  to  mistake  chorea 
for  any  other  affection.  Choreic  movements  are  entirely 
unlike  the  tremor  of  paralysis  agitans.  mercurial,  satur- 
nine or  alcoholic  trembling. 

The  Prognosis  is  favorable,  but  relapses  often  occur, 
and  in  very  severe  cases  the  general  health  seriously  suf- 
fers. 

Treatment.  Choreic  children  should  not  be  allowed  to 
attend  school.  Any  unnecessary  allusion  to  the  affec- 
tion in  the  hearing  of  the  patient  ought  to  be  avoided. 
The  child  should  be  guarded  against  doing  injury  to 
itself.  Mild  cases  require  little  medicine.  Bromide  of 
potassium  in  rather  large  doses  is  decidedly  of  benefit. 
An    anaemia    should    be   improved    by   iron.     A    palpa- 


CHOREA.  267 

ble  intestinal  irritation  requires  appropriate  treatment. 
Arsenic  is  the  approved  remedy  in  acute  and  protracted 
cases.  Five  drops  of  Fowler's  solution  may  be  given 
three  times  a  day.  The  arsenic  is  sometimes  advantage- 
ously combined  with  a  bromide.  Da  Costa  found  hyoscya- 
mine  in  doses  of  gr.  t^o  of  much  benefit  in  the  insomnia 
caused  by  unremitting  choreic  movements.  Valerianate 
of  zinc  and  nitrate  of  silver  are  also  recommended. 
Narcotics  according  to  general  experience  are  not  suit- 
able in  chorea.  Electric  treatment  very  often  disappoints. 
Chorea  in  pregnancy  usually  subsides  after  delivery. 
Cases  are  reported  in  which  artificial  delivery  was  neces- 
saij. 

As  an  appendix  to  the  subject  of  chorea  a  class  of  cases 
may  be  fittingly  mentioned  characterized  by  irresistible 
impulsive  movements.  The  "dancing  mania"  "tarant- 
ism  "  and  "electric  chorea," which  prevailed  from  time  to 
time  in  Europe  in  an  epidemic  form  belong  to  this  cate- 
gory. Motor  disorders  of  an  analogous  nature,  exhibit- 
ing quasi-involuntary  movements  are  occasionally 
brought  under  notice.  These  morbid  phenomena  totally 
differ  from  chorea.  They  probably  belong  to  the  category 
of  hysterical,  maniacal  or  epileptic  paroxysms;  or  per- 
haps are  allied  to  the  phenomena  of  trance,  ecstasy,  etc. 
The  following  brief  notes  of  a  case,  which  I  had  oppor- 
tunity to  observe  may  exemplify  the  characters  of  these 
strange  phenomena. 

A  girl  nine  years  of  age  had  suffered  for  the  past  two 
years  as  her  mother  told  me,  from  '"nervous- attacks." 
The  child  in  the  midst  of  play  would  suddenly  begin  to 
make  a  noise  like  some  animal,  and  then  contort  its  body, 
throw  about  the  arms  in  a  wild  manner,  kick  the  furni- 


St8  MANUAL  OF  NER  V  OUS  D  IS  EA  S  ES . 

ture,  jump  in  a  leap-frog  fashion,  scratch  the  walls,  tear 
its  clothes  and  perform  many  other  striinge  antics.  When 
I  saw  the  child  dming  one  of  these  attacks,  there  was  a 
constant  discharge  of  saliva  and  dribbling  of  the  urine;  the 
pupils  were  dilated,  but  consciousness  was  intact.  Any 
attempt  to  prevent  the  child  from  going  through  her 
maneuvres  only  increased  their  violence  and  duration. 
After  their  subsidence  the  child  resumed  its  normal  con- 
dition. 

ATHETOSIS. 

Dr.  Hammond  described  under  the  name  of  athetosis 
very  peculiar  involuntary  movements  entirely  differing 
from  chorea.  The  affection  is  almost  exclusively  confined 
to  children.  There  is  an  idiopathic  form  of  athetosis  of 
rare  occurrence,  which  appears  to  be  congenital  and  may 
be  attended  by  mental  weakness.  Athetosis  is  some- 
times a  post  hemiplegic  symptom  and  may  be  associated 
with  epilepsy. 

The  characteristic  movements  are  most  conspicuous  in 
the  hand  and  fingers  as  illustrated  in  figures  28  and  29. 
The  fingers  are  never  at  rest.  They  are  constantly  either 
flexed,  extended  or  intertwined  in  the  most  curious  man- 
ner. The  singular  positions  they  assume  is  due  to  an 
irregular  elongation  from  continued  stretching  of  the 
articular  ligaments.  The  arms  and  inferior  extremities 
are  less  affected,  but  the  toes  sometimes  are  involved  in 
movements  analogous  to  those  of  the  fingers.  If  the  facial 
muscles  participate  in  the  movements,  they  are  twisted 
and  contorted.  The  head  is  thrown  forward,  backward 
and  sideways,  if  the  muscles  of  the  neck  are  implicated. 


ATHETOSIS.  269 

Xo  anatomical  changes  are  observed  in  idiopathic 
athetosis.  Probably  the  source  of  irritation  is  in  the 
brain. 

Improvements  of  the  movements  is  sometimes  obtained 
from  galvanism,  the  bromides,  or  Fowler's  solution. 


Fig   29. 


TETANY. 

Etiology.  Tetany  is  characterized  by  intermittent  tonic 
tonic  spasms  of  certain  groups  of  muscles.  The. disease 
occurs  in  children  and  young  adults.     Trousseau  found 


•270  MA  NUAL  O  F  XER  V  OUS  DISEAS  ES . 

tetany  rather  frequent  in  young  nursing  women.  In 
many  cases,  a  rheumatic  influence  is  probably  the  excit- 
ing cause.  A  co-existent  diarrhoea  has  also  been  observed. 
The  disorder  sometimes  appears  in  an  epidemic  form 
among  girls  at  school.  Tetany  has  been  known  to  follow 
the  removal  of  the  thyroid  gland. 

Clinical  History.  Certain  precursory  symptoms  make 
their  appearance.  Pain  is  felt  in  the  arms  and  a  sensa- 
tion of  coldness  and  tingling  in  the  fingers.  After  a  few 
hours  the  seizure  begins  in  the  fingers,  they  become  stiff 
and  the  hands  the  arms  and  inferior  extremities  in 
succession  are  affected  with  contractions.  Spasm  of  the 
flexors  predominate.  The  fingers  approximate,  the  term- 
inal phalanges  are  extended,  the  metocarpel  ends  are 
flexed,  the  thumb  is  strongly  abducted  and  the  palm  is 
hollowed.  This  position  of  the  hand  resembles  the 
peculiar  form  which  it  is  made  to  assume  by  the  accouch- 
eur, when  he  introduces  the  hand  into  the  vagina.  In 
severe  cases,  the  upper  arm  is  pressed  against  the  chesty 
the  elbow  is  slightly  flexed  and  the  forearms  are  crossed 
over  the  epigastrium.  In  attacks  of  the  inferior  extremi- 
ties, the  toes  are  bent,  and  the  feet  are  in  the  position  of 
talipes  equinus.  The  rest  of  the  voluntary  muscles  are 
not  often  involved. 

The  muscles  in  the  condition  of  tonic  contraction  feel 
very  hard  and  stiff,  and  even  after  an  attack  they  do  not 
completely  relax.  Certain  characteristic  phenomena  are 
observed  during  the  intervals.  The  peripheral  nerves  are 
found  very  sensitive  to  electric  excitation,  violent  con- 
tractions being  evoked  by  weak  currents.  Mechanical 
stimulation  of  the   muscles   show  an   analogous  excita- 


TETANY.  21 1 

bility.  Thus,  the  facial  muscles  can  be  made  to  contract 
by  stroking  them  with  the  hand.  Trousseau  discovered 
that  in  many  cases  energetic  contractions  can  be  excited 
by  pressure  of  the  arm  in  the  regions  of  the  median  nerve 
and  the  brachial  artery.  As  long  as  "Trousseau's  sign" 
exists  the  recurrence  of  the  paroxysms  may  be  expected. 

The  frequency  of  contractions  vary  in  individual  cases. 
Sometimes  there  is  a  long  pause  between  them,  and  in 
others  they  are  nearly  continuous.  An  attack  generally 
lasts  about  two  weeks.  Prognosis  is  always  favorable. 
No  anatomical  lesion  has  yet  been  detected  to  account  for 
the  disorder. 

Diagnosis.  A  careful  consideration  of  the  symptoms 
which  have  been  described  as  characteristic  of  tetany  can 
hardly  fail  to  render  diagnosis  easy.  As  tetany  bears 
considerable  resemblance  to  the  very  rare  disorder  called 
"  arthogryposis"  a  few  notes  will  be  added  here  to  point 
out  the  peculiarities  of  the  latter  disease. 

Art]iO(jryposis  usually  occurs  in  children,  and  may  be  attended  by 
febrile  symptoms  throughout  its  whole  course.  Its  essential  symptoms 
consist  of  tonic  spasms  of  one  or  of  all  four  extremities.  The  arms  are 
bent  and  the  fingers  flexed  so  as  to  assume  fixed  positions.  The  legs 
are  either  rigidly  extended  or  drawn  up  to  the  body.  Recovery  in 
mild  cases  may  take  place  in  a  few  weeks,  but  a  fatal  termination 
usually  happens  in  aggravated  cases.  The  autopsy  shows  no  dis- 
tinctive lesion. 

Treatment.  The  spasms  in  tetany  are  sometimes  promptly 
relieved  by  applying  the  anode  of  the  galvanic  current  to 
the  different  nerve  trunks  distributed  to  the  affected 
muscles  and  the  kathode  to  the  sternum.  Another 
method  consists  in  passing  the  current  through  the  spinal 
cord.    The  treatment  is  materially  assisted  by  cold  spong- 


^72  MA  N  UA  L   0  F  XER  V  0  US  D  IS  EA  S  ES . 

ing  of  the  back  and  friction.     The  bromides,  belladona 
and  arsenic  give  no  satisfactory  results. 

THOMSEN'S   DISEASE. 

(Congenital  Myotonia.) 

This  disease  was  first  described  by  Dr.  Thomsen,  a 
German  physician,  who  suffered  from  it  in. his  own  per- 
son and  observed  it  in  several  members  of  his  family.  A 
strong  hereditary  tendency  existed  in  the  not  numerous 
cases  that  have  come  under  notice. 

The  characteristic  symptom  of  the  affection  is  the 
occurrence  of  spasmodic  rigidity  of  voluntary  muscles 
when  they  are  called  into  action  after  intervals  of  rest. 
The  muscles  of  the  inferior  extremities  are  always 
affected.  When  the  patient  attempts  to  walk  he  succeeds 
for  a  little  while,  but  very  soon  the  muscles  of  the  limbs 
get  stiff,  so  that  he  must  come  to  a  halt.  After  a  short 
time  of  rest  the  muscles  relax,  but  the  longer  the  muscles 
have  rested  the  greater  will  be  the  difficulty  of  walking. 
No  outward -change  in  the  condition  of  the  muscles  is 
observed;  they  rather  appear  to  be  very  well  developed. 

Erb's  recent  investigations  show  that  the  individual 
muscular  fibers  are  rounded,  having  lost  their,  normal 
polygonal  appearance,  and  that  the  interstitial  tissue  is 
increased.  He  also  noticed  that  the  myotonic  reaction 
outlasts  the  direct  electrical  excitation  of  the  muscles. 
The  reflexes  and  the  sensations  are  normal.  No  addi- 
tional symptoms  exist.  Myotonia  is  a  life-long  disease. 
It  baffles  all  therapeutical  measures. 


CHAPTER  XV. 

EPILEPSY. 

Deflnition.  The  peculiarity  of  epilepsy  consists  in  an 
inexplicable  tendency  of  certain  nerve  centers  to  mani- 
fest, without  an  at^signable  cause,  at  irregular  periods,  a 
condition  of  excitement  that  gives  rise  to  a  typical  form 
of  generalconvulsions  in  individuals  who,  although  they 
may  have  been  subject  to  such  attacks  during  a  lifetime, 
show  no  distinctive  lesion  of  the  nervous  system  on  post 
mortem  examination.  According  to  our  present  knowl- 
edge we  must  characterize  epilepsy  as  a  purely  functional 
neurosis.  Convulsive  paroxysms  occurring  in  the  course 
of  various  diseases  are  symptomatic,  and  are  therefore 
distinguished  by  the  terms  "epileptiform"  or  "epileptoid." 

Etiology.  Although  the  essential  cause  of  epilepsy  is 
unknown,  we  are  acquainted  with  certain  conditions  and 
circumstances  which  act  as  predisposing  causes.  A 
hereditary  influence  can  be  traced  in  a  large  propor- 
tion of  cases.  The  descent  is  more  frequently  on  the 
mother's  side.  Often  the  transmission  is  not  direct,  but 
there  exists  a  family  tendency,  which  favors  the  develop- 
ment of  the  disease.  This  tendency  is  shown  by  the  fact 
that  members  of  the  same  family  are  prone  to  be  affected 
with  allied  nervous  affections.  It  may  be  insanity,  dypso- 
mania,  hysteria,  neuralgia,  etc.  Independent  of  a  hered- 
itary predisposition,  it  may  be  fairly  assumed  that  there 

18  I  -'73  ) 


27 J^  MANUAL   OF  NERVOUS  DISEASES. 

are  individuals  of  a  neurapathic  constitution  in  whom 
this  condition  is  manifested  by  the  development  of  epi- 
lepsy. Alcoholism  in  the  parent  is  believed  to  predispose 
to  this  disease  in  the  offspring.  Genuine  epilepsy  is  not 
caused  by  syphilis. 

Among  the  exciting  causes  of  epilepsy  are  understood 
those  influences  which  tend  to  develop  the  disease  in  per- 
sons who  are  predisposed  to  it.  The  most  important  is 
sudden  terror  or  fright.  Continued  worr}^  of  mind,  anx- 
iety and  disquietude  may  act  in  a  similar  manner.  In 
some  cases  the  occurrence  of  the  first  attack  has  been 
preceded  by  declining  health,  ansemia,  sexual  excesses, 
sunstroke  or  an  acute  febrile  disease. 

If  epileptic  spasms  occur  after  injuries  to  the  head 
from  a  blow,  fall  or  cut,  they  do  not  imply  true  epilepsy. 
In  these  traumatic  forms  of  epilepsy,  there  is  nearly 
always  a  cortical  lesion,  and  the  convulsive  movements 
are  usually  unilateral.  (Jacksonian  epilepsy.)  That 
form  of  epilepsy  caused  by  wounds  of  superficial  nerves, 
from  splinters  of  glass  or  other  foreign  substances  is  the 
so-called  "  reflex  epilepsy."  In  cases  of  this  kind  it  is 
highly  probable  that  patients  manifest  a  strong  tendency 
to  neurotic  affections.  Reflex  epilepsy  can  be  artificially 
produced  in  rabbits,  as  Brown  Sequard  has  demonstrated, 
by  injuring  the  medulla  oblongata  or  the  spinal  cord. 
Epileptic  attacks  are  excited  in  these  animals  by  irrita- 
ting certain  parts  of  the  skin — "  the  epileptogenous  zone." 
It  is  remarkable,  that  the  progeny  of  the  animals  so 
operated  upon  are  sometimes  subject  to  spontaneous 
epileptic  convulsions. 

Clinical  History.  An  epileptic  seizure  is  sometimes  pre- 
ceded for  hours  or  days  by  premonitory  symptoms,  chiefly 


EPILEPSY.  275 

consisting  of  headache,  vertigo,  restlessness  and  psychical 
disturbance.  In  the  greater  number  of  cases  the  "  warn- 
ing "  is  experienced  immediately  before  the  attack  sets 
in.  Such  premonitory  symptoms,  called  aura^,  consist  of 
sensory  motor,  vaso-motor  and  mental  disturbances. 

1.  The  epigastric  aura.  This  is  one  of  the  most 
frequent  of  premonitory  symptoms.  It  is  described  by 
patients  as  a  distressing  sensation  in  the  pit  of  the 
stomach,  attended  by  nausea  and  precordial  anxiety. 

2.  An  aura  of  great  frequency  is  a  peculiar  sensation 
beginning  in  the  legs  or  arms,  or  in  the  region  of  the 
heart  and  suddenly  "  going  to  the  head." 

o.  The  aur?e  referred  to  the  special  senses  relate  to 
optical  disturbances,  as  flashes  of  light,  colored  rings, 
sudden  blindness  ;  or  spectral  illusions,  such  as  horrible 
faces,  reptiles,  but  also  enchanting  scenes  and  pleasant 
visions.  Hallucinations  of  hearing  are  less  common. 
Some  epileptics  smell  foul  odors  or  have  a  metallic  taste 
in  the  mouth,  before  an  jittack. 

4.  Motor  aur«  are  of  various  kinds.  An  attack  may 
be  ushered  in  by  "  dragging  in  the  face,"  a  '^  slap  on  the 
head,"  a  choking  sensation,  or  a  strain,  as  if  going  to 
stool. 

5.  The  aura  of  a  vaso-motor  nature  refers  to  a  sudden 
feeling  of  chilliness,  flashes  of  heat  in  the  face  or  pallor^ 
sweating  or  violent  palpitations  of  the  heart. 

6.  The  most  frequent  psychical  aura  is  a  feeling  of 
alarm  and  anxiety.  The  patient  looks  startled,  fright- 
ened or  amazed.  Sometimes  he  is  in  a  dreamy  state,  the 
past  events  of  his  life,  crowding  upon  his  memory. 

These  premonitory  symptoms  in  individual  cases  are 
often   variously    combined.      Sometimes    they   last   long 


S76  MA  X  UA  L   OF  NER  VOUS  DISEASES . 

enough  to  apprize  the  patient  of  the  coming  attack,  l)ut 
as  a  rule  the  convulsions  immediately  follow. 

It  is  usual  in  describing  the  epileptic  paroxysm  to 
make  the  division  of:  1.  Epilepsia  gravior  or  grand  mal; 
2.  Epilepsia  mitior,  or  petit  mal;  3.  Epileptoid  condi- 
tions. 

1.  Epilepsia  Gravior.  An  epileptic  attack  whether 
preceded  by  an  aura  or  not  invariably  begins  abruptly. 
Many  patients  utter  a  peculiar  cry  at  the  onset, — "  the 
epileptic  cry" — although  they  are  already  unconscious, 
and  suddenly  fall  headlong  to  the  ground.  Consciousness 
and  sensibility  are  completely  abolished  and  tonic  spasm 
of  brief  duration  seizes  the  whole  body.  The  head  is 
strongly  extended,  the  pupils  dilated,  the  conjunctiva 
insensible,  the  jaws  firmly  closed;  the  tongue  is  frequently 
bitten  and  bloody  froth  accumulates  at  the  mouth.  Pallor 
of  the  face  is  well  marked  at  the  beginning.  The  back  is 
arched  as  in  aposthotenos,  the  arms  are  firmly  flexed  and 
the  inferior  extremities  are  rigidly  extended.  The  respira- 
tory muscles  are  involved,  the  breathing  is  arrested  and 
the  color  of  the  face  is  bluish  or  dusky.  This  stage  lasts 
from  15  to  30  seconds  and  is  followed '  b\M he  stage  of 
clonic  spasms. 

The  face  in  this  stage  assumes  a  hideous  appearance. 
All  the  features  are  contorted;  the  eyes  roll  wildly  in 
their  orbits,  the  tongue  is  thrust  out  and  convulsively 
retracted,  the  head  beats  upon  the  ground,  and  the  arms, 
the  trunk  and  the  legs  are  violently  convulsed.  Some- 
times the  contents  of  the  bladder  and  the  rectum  are 
evacuated  and  seminal  emissions  take  place.  The  pulse 
and  temperature  remain  normal,  but  during  the  venous 
stasis,  the    heart   is  tumultuous  and  the  carotids  throb. 


EPILEPSY.  'm 

Ecchymotic  spots  appear  in  the  conjunctivae  and  upon 
the  skin  in  the  region  of  the  neck.  This  stage  lasts  from 
1  to  10  minutes. 

The  third  stage  is  characterized  by  the  disappearance  of 
the  cyanosis  and  the  gradual  return  to  a  natural  respira- 
tion. The  patient  is  still  unconscious,  but  he  begins  to 
change  the  position  of  his  body,  he  opens  his  eyes,  looks 
about  in  a  kind  of  a  dazed  condition  and  then  soon  passes 
into  a  slumber  which  may  last  a  few  hours.  Some 
patients  recover  quickly,  so  as  to  be  able  to  attend  to 
their  usual  occupation  in  less  than  half  an  hour.  Gen- 
erally complete  recovery  from  an  attack  is  delayed  much 
longer.  For  a  day  or  two  patients  suffer  from  headache, 
lassitude  and  an  irritable  mental  disposition.  A  large 
quantity  of  urine  is  often  passed  immediately  after  a 
seizure,  which  contains  traces  of  albumen. 

2.  Petit  mal.  The  mild  forms  of  epilepsy  may  begin 
with  or  without  an  aura,  and  be  variously  manifested. 
Sometimes  the  petit  mal  merely  amounts  to  a  moment- 
ary confusion  of  mind,  attended  or  not  by  slight  twitch- 
ing of  facial  muscles  or  contraction  of  the  hands,  which 
quickly  subsides.  Such  a  minor  attack  may  stop  a 
patient  in  the  midst  of  a  conversation,  or  while  engaged 
in  his  usual  occupation.  Sometimes  it  is  merely  a  fit 
of  dizziness  or  faintness  which  rapidly  passes  off  "and  leaves 
the  patient  unaware  that  anything  unusual  has  hap- 
pened to  him.  In  others  the  whole  attack  may  only  con- 
sist of  a  sudden  contortion  of  the  face,  or  fixidness  of  the 
eyes,  or  a  scream,  or  a  reeling  of  the  body.  The  patient 
knows  nothing  of  it,  and  those  who  happen  to  witness 
these  phenomena,  may  think  them  rather  odd,  but  usually 
attach    no   importance   to    them.     Very  strange  acts  are 


f>18  MA  N  UAL   OF  NER  VO  US  DISEASES. 

sometimes  unconsciously  performed  by  patients  during 
minor  attacks  of  epilepsy.  Trousseau  relates  the  case  of 
a  judge,  who  in  open  court  would  leave  his  seat  and 
answer  a  call  of  nature  in  a  corner  of  the  room,  then 
return  to  his  place,  entirely  oblivious  of  what  he  had  done. 
These  "  faints  or  spells  "  as  these  incomplete  seizures  are 
popularly  called,  rarely  excite  much  alarm  in  the  friends 
of  the  patient.  The  medico-legal  bearing  of  such  cases 
is  sometimes  very  important.  One  of  my  patients  often 
fell  into  the  hands  of  the  police  for  exposing  his  person 
in  the  public  streets.  He  was  at  times  afflicted  with 
grand  mal. 

3.  The  Epileptoid  condition.  The  s3^mptoms  under 
this  head  have  not  been  unapth^  called  the  "  equiva- 
lents of  epilepsy."  They  consist  of  aberrations  of  con- 
sciousness either  of  a  paroxysmal  and  transient  nature 
or  succeed  to  a  typical  or  rudimentary  fit  of  epilepsy. 
Various  psychical  disturbances  may  immediately  follow 
an  attack  which  shows  the  intimate  connection  between 
them.  But  the  nature  of  the  mental  derangement  occur- 
ring independently  of  an  attack  would  not  be  easily 
recognized  if  the  individual  were  not  known  to  be  sub- 
ject to  epilepsy.  Aggressive  and  even  violent  criminal 
acts  may  thus  be  committed  in  the  epileptoid  condition. 
Such  a  form  of  transient  insanity  is  recognized  by 
alienists.  The  diagnosis  would  harldy  remain  doubtful, 
if  in  addition  to  the  brutal,  ferocious,  unprovoked  act 
devoid  of  all  known  motive  and  which  after  its  commission 
appears  inexplicable  and  abhorrent  to  the  accused,  there 
is  evidence  that  he  had  previous  attacks  of  epilepsy.  In 
children  and  very  young  persons,  the  epileptoid  condition 
is  commonly  exhibited  by  unaccountable  behavior,  vicious 


EPILEPSY.  279 

propensities  and  especially  a  remarkable  tendency  to 
incendiarism. 

Course  of  the  disease.  Nocturnal  epilepsy  is  a  peculiar- 
ity of  some  importance,  as  the  existence  of  the  disease 
may  be  concealed  for  a  long  time  if  the  attacks  only 
occur  during  sleep.  This  condition  may  be  suspected  if 
patients  continually  suffer  from  sore  tongue  or  frequently 
wet  the  bed.  There  is  no  uniformity  in  regard  to  the  fre- 
quency of  attacks.  Some  have  only  one  or  two  during  the 
year,  others  have  them  every  month  or  daily.  A  similar  dif- 
ference obtains  in  regard  to  the  severity  of  the  seizures. 
Many  patients  have  none  but  the  grand  mal;  some  have 
also  minor  attacks;  and  in  another  class,  the  very  mildest 
form  of  the  disease  or  the  epileptoid  condition  predom- 
inates. 

Genuine  epilepsy  develops  in  youth,  rarely  after  thirty. 
The  general  health  and  the  intellectual  faculties  may- 
remain  unimpaired  through  a  life-long  existence  of  the 
disease.  When  mental  deterioration  occurs,  the  memory 
is  the  first  to  suffer,  which  ultimately  terminates  in 
hopeless  dementia.  In  very  rare  cases,  the  seizures 
become  violent  and  recur  in  rapid  succession.  This 
"status  epilepticus  "  is  a  very  dangerous  condition  and 
usually  ends  in  death.  Various  influences  favor  the 
recurrence  of  attacks.  The  baneful  effects  of  alcoholism, 
venereal  excesses,  physical  overwork  and  mental  excite- 
ment are  undeniable.  On  the  other  hand  a  peaceful  life^ 
moderation  and  genial  surroundings  exert  a  beneficial 
influence  in  reducing  the  repetition  of  the  seizures.  Epi- 
leptic girls  sometimes  improve,  when  they  arrive  at  the 
menstrual  period:  more  frequently   this  epoch  develops 


S80  M  A  XUA  L  OF  XER  VO  US   D  I  SEA  SES. 

the  disease.     That  marriage  exerts  a  favorable  infiuence 
oil  epilepsy,  is  not  sustained  by  experience. 

Pathology.  Anatomical  changes  of  the  cerebral  meninges 
and  blood-vessels  are  not  unfrequently  found  in  long 
standing  cases  of  epilepsy,  but  such  morbid  appearances 
are  of  a  secondary  character  and  are  not  uniformly 
present.  Atrophy  of  the  hemispheres  is  sometimes  seen 
in  subjects  who  died  of  epileptic  dementia.  Induration 
of  the  pes-hippocampi  minor  is  more  frequently  seen 
than  any  other  sort  of  lesion  in  epilepsy,  but  it  is  not  a 
constant  lesion.  In  the  absence  of  a  distinctive  anatom- 
ical change  that  might  give  a  clue  to  the  nature  of  the 
disease  we  may  perhaps  come  nearer  a  solution  of  the 
problem,  if  the  starting  point  of  the  epileptic  paroxysm 
could  be  determined.  It  was  for  a  long  time  supposed, 
that  the  medulla  oblongata,  which  is  the  general  reflex 
center,  is  the  region  where  the  epileptic  commotion 
originates.  Nothnagel  in  more  recent  times,  thought 
that  he  had  found  a  ''convulsive  center"  in  the  pons. 
The  cortical  origin  of  epilepsy  finds  at  present  most  favor 
among  neurologists.  This  view  certainly  agrees  best  with 
clinical  facts.  In  the  first  place,  the  loss  of  conscious- 
ness, which  is  one  of  the  essential  symptoms  of  the 
epileptic  attack,  is  a  psychical  phenomenon,  and  there- 
fore a  cortical  disturbance.  And  again,  some  of  the  aurae 
are  of  a  purely  mental  nature.  In  the  second  place,  the 
spasmodic  movements  which  are  epileptic  phenomena  of 
equal  importance  occur  in  lesions  of  the  cortex.  "  Cor- 
tical epilepsy  "  artificially  produced  in  animals  attacks 
the  muscles  in  the  same  order  which  is  observed  in  the 
epileptic  seizure  in  man.  This  whole  subject  has  been 
admirably    discussed  by  Hughlings   Jackson.     But  the 


EPILEPSY.  '^St 

nature  of  that  morbid  irritation  which  spontaneously 
initiates  the  convulsive  paroxysm  of  epilepsy  is  still  a 
mystery. 

Diagnosis.  It  is  very  unusual  to  mistake  a  case  of 
epilepsy.  Although  the  epileptiform  convulsions  in  cere- 
bral tumor,  abscess  and  syphilis  greatly  resemble  those  of 
true  epilepsy,  yet  the  intermediate  clinical  history  of 
organic  brain  disease  decides  the  differential  diagnosis. 
"  Jacksonian  epilepsy  "  is  generally  unilateral  and  always 
depends  on  a  cortical  lesion.  Hysterical  convulsions  as 
already  pointed  out  are  never  confounded  with  epilepsy, 
by  the  experienced  physician.  In  ur?emic  spasms  there 
is  permanent  albuminuria. 

Treatment.  In  the  rare  cases  of  ''  reflex  epilepsy  "  .per- 
manent benefit  may  follow  surgical  procedures.  Trephin- 
ing of  the  skull  in  superficial  tumor  or  abscess  has 
achieved  some  brillant  cures.  In  genuine  epilepsy  no 
indications  for  causal  treatment  exist.  There  is  no  doubt 
that  the  frequency  of  attacks  is  lessened,  if  the  patient 
observes  a  proper  diet  and  regimen  and  practices  regular 
habits  of  life.  Alcoholic  stimulants  are  decidedly  inju- 
rious, even  coffee  and  tea  are  better  avoided.  Indigest- 
ible food,  heavy  meals  and  in  fact  excesses  of  all  kinds 
favor  the  occurrence  of  the  attacks.  A  strict  vegetable 
diet  has  many  advocates. 

Among  the  remedies  employed  in  the  treatment  of 
epilepsy,  there  are  certainly  none  which  equal  in  efficacy 
the  several  bromides.  The  bromide  of  potassium  is  the 
one  usually  preferred.  It  should  be  given  in  large  doses 
and  continued  for  months  and  even  much  longer,  if  it  be 
found  of  service.  One  drachm  a  day  is  the  usual  dose  to 
begin  with,  but  may  be  increased  to  the  maximum  dose 


2Se  MANUAL   OF  NERVOUS  DISEASES. 

of  2\  dr.  a  day  if  the  attacks  are  severe  and  frequent. 
Smaller  doses  suffice  should  improvement  follow.  The 
remedy  should  be  much  diluted  in  water  to  prevent  irri- 
tation of  the  stomach,  and  for  the  same  reason  it  is  advis- 
able to  gi  7e  the  daily  quantity  in  divided  doses.  The  other 
bromides,  the  sodic,  the  amnionic  and  lithic  may  be 
advantageously  combined  with  the  bromide  of  potassium. 
One  part  of  each  of  the  sodic  and  amnionic  with  two 
parts  of  the  bromide  of  potassium  form  a  good  combina- 
tion. The  bromide  of  sodium  agrees  better  with  delicate 
stomachs.  The  bromide  of  lithia  contains  the  largest 
percentage  of  bromine,  but  is  not  superior  to  the  other 
bromides'.  The  quantity  of  these  medicines  must  be 
diminished  or  wholly  omitted  for  a  time  if  brominism 
appears.  Its  symptoms  are  an  eruption  of  acne,  tremor, 
dyspepsia,  impotence,  cardiac  weakness  and   dejection. 

Belladonna  enjoyed  formerly  a  high  reputation  in 
Epilepsy,  but  is  far  inferior  to  the  bromides.  It  is 
given  in  pills  of  the  extract  or  in  the  form  of  atropia  in 
equivalent  doses  of  gr.  yk  three  times  a  day.  Dr.  Gowers 
recommends  a  combination  of  belladonna  with  one  of  the 
bromides. 

The  oxide  of  zinc  is  an  old  remedy  for  fits.  From  2  to 
8  grains  combined  with  gr.  \  of  belladonna  extract  and 
15  grains  of  valerian  root  powder,  three  times  a  day,  is  a 
favorite  prescription  with  good  observers  after  failure  of 
the  bromide  treatment. 

Borax  has  lately  been  much  lauded  in  doses  from  10 
to  15  grains  three  times  daily. 

It  is  needless  to  do  more  than  allude  to  other  remedies 
that  are  recommended  for  epilepsy,  such  as  nitrate  of 
silver,  arsenic,  indigo  and  preparations  of  copper,  as  they 


MtN lERE'S  DISEASE.  283 

are  rarely  of  benefit.    Electricity  does  not  appear  to  exert 
any  influence  in  epilepsy. 

Various  popular  measures  are  in  use  to  prevent  an 
attack  when  the  patient  has  a  ''warning,"  such  as 
slapping  the  palms  of  the  hands,  a  brisk  walk,  and 
stuffing  the  mouth  with  salt.  Nothing  should  be  done 
during  the  attack  except  to  guard  the  patient  against 
injury.  If  the  tongue  is  caught  between  the  teeth,  a  gentle 
effort  should  be  made  to  release  it. 

MENIERE'S    DISEASE. 

Aural  Vertigo. 

Etiology.  Chronic  disease  of  the  ear,  affecting  the 
labyrinth  and  semi-circular  canals  is  supposed  to  be  the 
cause  of  the  peculiar  disease  to  which  attention  was  first 
drawn  by  Meniere.  It  is  sometimes  attended  by  otorrhoea 
and  deafness. 

Clinical  History.  The  chief  symptoms  of  the  disease  are 
tinnitus  aurium  and  excessive  vertigo.  It  begins  with 
shrill  voices  heard  in  one  or  both  of  the  ears,  accompanied 
by  dizziness,  nausea  and  vomiting.  Later,  the  paroxysms 
occur  frequently,  at  short  intervals,  and  finally  the 
vertigo  is  so  continuous  and  severe  that  the  patient  has  to 
keep  to  his  bed.  During  the  exacerbations  of  the  vertigo? 
the  patient  has  a  sensation  as  if  his  body  were  whirled 
about  in  every  possible  direction,  and  with  such  a  force 
that  he  clutches  at  surrounding  objects  to  prevent  falling 
to  the  ground.  Towards  the  end  of  the  attack  a  very 
distressing  feeling  of  nausea  comes  on,  the  face  is  pallid 
and  cold,  and  the  body  is  covered  with  perspiration. 

After  having  progressed  for  several  years  complete 
deafness  ensues,  and   with   its  appearance  all    the  other 


S84  MANUAL  OF  NERVOUS   DISEASES. 

symptoms  cease.     Meniere's  disease  may   be  confounded 
with  epilepsy  and  disease  of  the  cerebellum. 

Treatment.  Special  treatment  of  the  ear,  when  called  for 
is  of  primary  importance.  Quinia  appears  to  give  always 
relief.  From  10  to  15  grains  should  be  given  daily. 
Politzer  reports  remarkable  results  from  hypodermic 
injections  of  pilocarpin. 

HYSTERIA. 

Etiology.  The  multifarious  and  bizarre  phenomena, 
which  cannot  be  referred  to  a  definite  pathological  change, 
but  which  bear  a  stamp  and  present  a  physiognomy  that 
the  experienced  physician  recognizes  at  a  glance  lend  to 
hysteria  the  character  of  a  singular  disorder  but  one  of 
great  clinical  importance.  Symptoms,  capricious,  erratic 
and  anomalous,  ranging  from  a  mild  group  of  functional 
nervous  disturbances  up  to  an  apparent  formidable  impli- 
cation of  important  nerve  centers,  and  frequently 
disappearing  suddenly  ^without  leaving  a  trace  behind, 
show  that  no  tangible  morbid  condition  affects  a  par- 
ticular organ  or  tissue.  The  fact  that  hysterical  mani- 
festations are  eminently  excited  by  psychical  influences 
strongly  supports  the  view  that  the  nervous  system, 
and  especially  the  higher  centers  are  aff'ected  with  a 
peculiar  irritability  or  with  defective  inhibitory  power. 
Hysterical  persons  certainly  exhibit  an  impressible 
disposition  which  is  either  hereditar}^  or  acquired.  This 
neuropathic  condition  greatly  preponderates  in  the  female 
sex.  It  is  not  difficult  to  understand  why  the  delicacy 
of  the  nervous  apparatus  in  women  readily  reacts  in  an 
undue  manner  to  exciting  causes  that  hardly  aff'ect  the 
stronger  sex.     Hysterical  symptoms   in   girls   frequently 


HYSTERIA.  mo 

make  their  first  appearance  at  the  period  of  pubes- 
cence. Of  a  similar  influence  is  the  recurrence  of  the 
menstrual  molimen.  Uterine  and  ovarian  troubles, 
chlorosis  and  £in«mia  often  lay  the  foundation  of  a  life- 
long hysteria.  But  the  prominence  formerly  attributed 
to  disturbances  of  the  sexual  organs  in  the  female  as 
exciting  causes  of  hysteria  is  not  sustained  by  experience. 
That  boys  are  not  unfrequently  affected  with  hysterical' 
symptoms  cannot  be  disputed.  Even  men  under  the 
mfluence  of  shock  or  strong  emotional  excitement  some- 
times go  through  a  paroxysm  of  genuine  hysteria.  A 
tendency  to  the  development  of  hysteria  must  be  assigned 
to  the  injurious  effects  of  mental  strain,  especially  of  a 
depressing  nature.  To  this  category  of  exciting  causes 
belong  deep  anxiety,  concealed  sorrow,  disappointment 
and  harsh  treatment.  It  is  alleged,  that  the  frivolities 
and  artificial  excitement  in  which  females  in  affluent 
circumstances  indulge  augment  the  number  of  hysterical 
patients.  But  women  m  humble  walks  of  life  are 
certainly  not  exempt.  A  deleterious  influence  must  also 
be  attributed  to  the  ill-directed  training  of  little  girls 
who  give  intimation  of  a  precocious  disposition,  or  betray 
odd  or  morbid  susceptibilities.  Very  remarkable  and 
puzzling  are  the  histories  of  hysterical  individuals,  who 
nurse  and  pet  without  a  sinister  motive  some  spurious 
ailment,  that  subjects  them  to  a  miserable  state  of 
existence  and  actual  deterioration  of  health  in  order  to 
keep  up  the  role  they  assume.  It  would  be  difficult  to 
account  for  such  phenomena  were  it  not  for  the  fact,  that 
they  represent  phases  of  hysteria.  Probably  some  of  this 
class  of  hysterical  persons  might  be  brought  to  confess 
that  the  undue  anxiety  and   slavish  ministration   spent 


283  MANUAL  OF  NERVOUS  DISEASES. 

upon  them,  has  fostered  their  n:iorbid  craving  for  sym- 
pathy and  their  desire  to  become  the  objects  of  interest 
and  solicitude. 

The  hysterical  element  is  also  strongly  developed  in 
cases  where  a  slight  hurt  or  insignificant  accident  con- 
centrates attention  upon  a  particular  part  of  the  body.  It 
is  usually  a  large  joint  or  the  spine  where  the  hysterical 
neurosis  locates. 

It  would  be  an  error  to  suppose  that  hysteria  is  con- 
fined to  anaemic,  feeble  and  broken  down  w^omen.  The 
exhibition  of  decided  hysterical  symptoms  in  women 
otherwise  healthy  and  vigorous  is  a  matter  of  common 
experience. 

Clinical  History.  Considering  the  diversity  of  hysterical 
symptoms  even  in  the  same  patient  it  would  be  a 
questionable  undertaking  to  give  a  description  of  a 
typical  case  of  the  disorder.  But  the  recurrence  of  a 
uniform  order  of  symptoms  or  a  particular  one  in  the 
same  patient  is  quite  often  observed. 

Hysterical  convulsions.  Not  every  hysterical  female  is 
subject  to  convulsions,  though  an  attack  is  prone  to 
develop  under  the  influence  of  strong  mental  excitement. 
In  some  cases  there  is  a  brief  prodromic  stage  char- 
acterized by  a  feeling  of  lassitude,  epigastric  uneasiness, 
a  choking  sensation,  fluttering  in  the  region  of  the  heart 
and  vague  pains  in  different  parts  of  the  body.  Some- 
times these  symptoms  stop  short  and  terminate  in  a  fit 
of  spasmodic  crying  or  laughter. 

The  convulsive  movements  in  hysteria  are  of  a 
tumultuous  character.  The  limbs  are  either  wildly  thrown 
about,  or  the  arms  and  hands  are  contorted  and  twisted. 
The     facial    muscles  are  not  affected,    but   the  patient 


HYSTERIA.  287 

makes  all  kinds  of  grimaces,  expressive  of  anger,  fright 
or  terror.  There  is  sometimes  unconsciousness  but  the 
mind  is  usually  unimpaired.     The  pupils  are  normal. 

In  another  class  of  cases,  tonic  contractions  are 
prominent.  The  arms  are  bent,  the  fingers  semiflexed, 
and  the  inferior  extremities  extended.  An  attack  often 
consists  of  partial  spasm  of  a  limb  or  some  group  of 
muscles.  Laryngeal  spasm  interferes  with  breathing. 
Sometimes  the  respiration  is  remarkably  rapid,  and  the 
heart  beats  violently.  Spasm  of  the  pharynx  and  of  the 
oesophagus  is  believed  to  give  rise  to  "globus  hystericus," 
which  patients  compare  to  a  ball  rising  or  sticking  in 
the  throat.  Spasm  of  the  diaphragm  causes  incessant 
hiccough,  often  accompanied  by  severe  pain  in  the  pit  of 
the  stomach.  Hysterical  cough  has  a  harsh,  brassy 
sound,  unattended  by  expectoration.  The  loud  move- 
ment of  gases  in  the  intestines  causes  the  annoying 
"  borborygmae."  A  great  variety  of  other  forms  of  hys- 
terical spasm  occur  ^hich  hardly  need  mention. 

A  case  comes  now  and  then  under  notice  in  which  the 
hysterical  and  epileptic  elements  seem  to  be  blended. 
French  authors  give  frightful  pictures  of  "  hystero- 
epilepsy."     They  are  seldom  witnessed  in  this  country. 

A  genuine  hysterical  fit  is  easily  distinguished  from 
epilepsy.  There  is  seldom  complete  coma  in  hysteria,  no 
initial  cry,  the  pupils  are  not  dilated,  the  face  is  not 
cyanotic,  there  is  no  biting  of  the  tongue,  and  the  spas- 
modic contractions  have  not  the  rhythmical  jerk  of 
epilepsy.  Besides,  the  duration  of  hysterical  convulsions 
is  indefinite. 

Psychical  characteristics  of  hysterical  individuals.  It  is 
especially  in  the  sphere  of  emotional  life,  the  sensibilities, 


^^88  MANUAL   OF  NERVOUS   DISEASES. 

the  mood,  temper  and  disposition,  that  the  peculiarities  of 
the  hysterical  element  become  manifest.  The  unbalanced 
state  of  the  emotions  is  exhibited  in  sudden  transitions 
from  gayety  to  sadness.  There  is  a  passiveness  to  the 
play  of  fancy  and  whim;  singular  likes  and  dislikes  arise; 
sometimes  an  unaccountable  apathy  and  stolid  indiffer- 
ence or  an  overcharged  enthusiasm  and  a  highly  wrought 
pathetic  sentimentality  is  exhibited.  There  may  be  a 
morbid  desire  to  create  interest  and  to  attract  sympathy. 
Slight  impressions  produce  exaggerated  effects.  The  inclin- 
ations and  the  will  seem  to  be  perverted,  as  shown  in 
uncontrollable  obstinacy  and  waywardness.  Hysterical 
individuals  who  are  more  or  less  affected  in  this  manner 
are  an  enigma  to  their  friends  and  acquaintances,  and  des- 
pots in  their  families.  But  hysterical  females  can  render 
themselves  very  agreeable  if  they  like.  There  is  some- 
times a  line  languor  in  the  expression  of  their  eyes  and 
a  supplicating  tone  of  the  voice,  which  novelists  are 
fond  of  depicting.  Hysterical  individuals  are  usually 
of  a  bright  intelligence.  They  are  often  well  aware  of 
the  oddities  and  fancies  that  frequently  possess  them,  but 
they  ingeniously  explain  them  away  by  a  high-colored 
description  of  their  manifold  complaints. 

Hysterical  paralysis.  The  paralysis  in  hysteria  is  gener- 
ally of  the  paraplegic  type,  but  hemiplegia  is  not  rare. 
Most  frequently  the  paralysis  suddenly  develops  after  a 
mental  shock  or  a  strong  emotional  disturbance.  A 
peculiarity  of  hysterical  paralysis  is  the  ability  of  the 
patient  to  move  the  limbs  well  enough  when  in  bed  or 
reclining,  but  when  requested  to  rise  she  immediately 
sinks  to  the  floor.  One  is  tempted  to  suggest  that  the 
patient  might  easily  get  up    and   walk   by   an  effort  of 


HYSTERIA.  289 

the  will,  but  this  command  of  the  will  is  just  what  is 
wanting.  The  paralysis  is  evidently  of  cerebral  origin. 
Another  peculiarity  of  hysterical  paralysis  when  only  one 
limb  is  affected  is  the  characteristic  gait.  The  paralyzed 
limb  does  not  describe  an  arc  when  carried  forward,  but 
the  patient  makes  a  long  stride  with  the  sound  limb 
and  the  other  is  dragged  along. 

Hysterical  aphonia  is  often  observed.  The  paralysis 
of  the  vocal  cords  comes  on  suddenly.  Its  existence  is 
revealed  by  the  laryngoscope.  The  reflex  excitability  of 
the  pharynx  is  sometimes  lowered  and  the  glottis  cannot 
be  completely  closed.  In  other  hysterical  individuals, 
usually  in  young  girls,  the  alteration  of  the  voice  con- 
sists in  the  utterance  of  shrill,  harsh  sounds. 

Hysterical  dysphagia  probably  depends  on  spasm  rather 
than  on  paralysis  of  the  oesophagus.  The  tube  can  be 
passed  after  a  brief  trial. 

Contracture  of  groups  of  muscles  is  sometimes  an  iso- 
lated hysterical  symptom,  or  it  is  associated  with  paral- 
ysis. Most  frequently  one  arm  or  the  hand  is  affected. 
The  arm  is  rigidly  contracted  and  the  fingers  are  inter- 
twined in  a  curious  manner.  Hysterical  contractures  are 
readily  relieved  by  morphia  injections  or  chloroform 
mhalations. 

Hysterical  aniesthesia.  One  of  the  most  remarkable 
symptoms  of  hysteria  is  complete  hemianaesthesia  gen- 
erally of  the  left  side.  The  loss  of  sensibility  is 
accurately  defined  by  the  median  line  of  the  body. 
All  the  qualities  of  common  sensation  are  abolished. 
The  patient  does  not  feel  the  nearness  of  a  lighted  can- 
dle, nor  the  prick  of  a  needle.     This  analgesia  explains 


S90  M  A  X UA  L  OF  NER  VO  US  D IS EA  SES . 

the  mutihitions  of  the  body,  which  hysterical  individ- 
uals have  been  known  to  practice  with  the  purpose  of 
eliciting  sympathy  or  for  a  sinister  motive.  In  another 
class  of  hysterical  patients,  the  ana?sthesia  is  confined  to 
limited  areas  of  the  skin,  affecting  also  the  neighboring 
mucous  membranes.  Disturbances  of  the  special  senses 
are  often  associated  with  anaesthesia  ;  —  amblyopia, 
amaurosis,  achromatopsia  and  narrowness  of  the  field  of 
vision.  There  may  be  impairment  of  hearing,  of  taste 
and  smell  on  the  affected  side.  A  very  singular  form  of 
paralysis  of  the  muscular  sense  has  been  described  by 
Duchenne.  The  patient  is  unable  to  tell  the  position  of 
a  limb  when  her  eyes  are  closed. 

Hypersesthesia  is  a  very  frequent  accompaniment  of 
hysteria.  It  is  often  associated  with  spasmodic  contrac- 
tions. Touch  or  pressure  in  many  parts  of  the  body 
elicits  pain.  The  head,  the  shoulders,  the  chest  and  the 
abdominal  walls  appear  to  be  highly  sensitive,  which 
suggests  to  the  patient  the  existence  of  some  serious  inter- 
nal disease.  Usually  the  patient  exaggerates  this  sensi- 
tiveness, as  is  discovered  when  her  attention  is  distracted. 
Whether  neuralgia,  which  may  be  present,  is  hyster- 
ical or  independent  of  the  disorder  is  difficult  to  decide. 
Intercostal  pain  is  the  most  constant  form  of  hysterical 
neuralgia  and  ovarialgia  is  sometimes  intense.  A  species 
of  pain  peculiar  to  hysteria  is  the  so-called  "clavus 
hystericus."  It  is  usually  limited  to  a  small  spot  along 
the  sagital  suture.  Hypersesthesia  of  special  sense  exists 
when  the  patient  complains  of  painful  sensitiveness  to 
light  or  of  acute  hearing.  A  perversion  of  the  gustatory 
sense  in  hysterical  girls  explains  their  relish  for  unsavory 
substances  and  their  dislike  to  ordinary  articles  of  food. 


HYSTElilA.  291 

Hypnotism.  Hypnotic  phenomena  which  can  be  artifi- 
cially produced  in  a  certain  class  of  people  occasionally 
occur  spontaneously  in  hysterical  individuals.  The  very 
obscure  nature  of  these  phenomena  surrounds  them  with 
much  mystery.  Since  Braide's  investigations  in  hypno- 
tism medical  men  have  begun  to  overcome  their  aver- 
sion to  a  subject  which  had  been  so  much  mixed  up 
wdth  charlatanry  and  deception.  A  variety  of  strange 
conditions  of  the  nervous  system  are  induced  b}^  dif- 
ferent methods,  such  as  stroking  the  head  with  the  hand, 
requesting  the  person  to  count  numbers,  to  look  con- 
tinually at  a  bright  object,  and  the  like.  A  condition 
of  lethargy  is  produced  in  which  the  subject  is  semi- 
conscious and  exhibits  a  remarkable  contractile  irrita- 
bility. A  faint  blow  upon  a  nerve  causes  a  spasmodic 
contraction  of  the  corresponding  muscle.  Charcot  in  his 
cases  of  this  description  observed  a  cataleptic  condition 
in  which  he  could  fix  the  limbs  and  position  of  the  body 
in  every  conceivable  way.  Of  greater  interest  are  the 
cases  of  "suggestion."  The  hypnotized  person  under  this 
influence  is  affected  with  hallucinations  in  which  he 
assumes  attitudes  and  goes  through  movements  in  corre- 
spondence with  the  special  suggestion.  By  a  change  of 
the  manipulations  the  hypnotized  person  passes  into  a 
state  of  somnambulism.  He  is  half  conscious,  describes 
visions  and  does  whatever  he  is  bid. 

A  number  of  nervous  disorders  affecting  different  organs 
remain  to  be  mentioned.  Frequent  attacks  of  palpitation 
are  very  alarming  to  hysterical  patients.  They  can 
usually  be  traced  to  a  previous  mental  excitement.  The 
pulse  is  occasionally  exceedingly  rapid  without  an 
apparent   cause.      Attacks    resembling   angina   pectoris 


S93  MANUAL   OF  XERVOUS  DISEASES. 

have  been  repeatedly  noticed.  ''Hysterical  hsemoptisis" 
and  "hysterical  hsematemesis"  belong  also  to  this  cate- 
gory of  anomalous  symptoms;  and,  stranger  still,  blood 
escapes  into  the  skin  (the  so-called  "stigmata").  These 
spontaneous  hemorrhages  cause  great  apprehension, 
though  leading  to  no  serious  consequences.  Digestive 
disturbances  are  often  well  marked.  "  Nervous  dyspepsia'' 
is  extremely  obstinate,  and  seems  to  baffle  all  remedies. 
"  The  phantom  tumor"  is  merely  a  partial  distension  of 
the  abdominal  walls,  and  if  very  extensive  may  simulate 
pregnancy.  Ischuria  is  a  very  remarkable  hysterical 
symptom.  Days  pass  by  and  no  urine  i^  discharged, 
though  there  is  no  retention.  Sometimes  violent  vomiting 
-comes  on,  and  examination  of  the  contents  of  the  stomach 
discovers  the  presence  of  urea.  It  is  highly  probable 
that  many  cases  of  obstinate  dysmenorrhoea  are  of  a 
hysterical  origin. 

Course  of  the  Disease.  It  will  be  observed  from  the  fore- 
going enumeration  and  description  of  the  medley  of 
symptoms  recognized  as  hysteria,  that  the  clinical  history 
of  this  affection  must  include  a  host  of  other  disorders, 
dependent  as  they  are  on  an  unstable  and  vulnerable 
nervous  system.  For  the  same  reason  it  cannot  be  pre- 
dicted what  different  ailments  will  arise  during  the  course 
of  the  disease.  Experience  has  taught  that  whilst  hyster- 
ical symptoms  may  entirely  disappear  for  an  indefinite 
period,  an  exciting  cause,  usually  some  emotional  dis- 
turbance, rekindles  the  morbid  tendency.  It  may  hap- 
pen that  none  of  the  more  severe  forms  of  the  disorder 
are  present  in  some  patients,  but  they  are  continually 
harassed  by  some  of  its  minor  ailments.  We  see  hysteri- 
cal women  who  are  never  satisfied  with  their    state  of 


HYSTERIA.  S93 

health;  they  are  always  invalids.  Some  special  com- 
plaint may  predominate.  It  may  be  nervous  dyspepsia, 
dyspnoea,  palpitation  or  a  worrying  pain  in  some  part  of 
the  body.  On  the  other  hand,  it  is  peculiar  to  hysteria 
that  severe  symptoms,  such  as  paralysis,  contractures, 
hemiansesthesia  or  convulsive  paroxysms,  disappear  sud- 
denly and  spontaneously. 

Diagnosis.  Hysteria  presents  a  physiognomy  of  symp- 
toms that  betrays  their  true  character.  Their  very 
puzzling  nature,  that  does  not  conforjn  to  the  etiology, 
clinical  history  and  course  of  well-known  individual 
diseases,  is  significant.  Hysterical  paralysis  as  pointed 
out  differs  from  ordinary  forms  of  paraplegia  and  hemi- 
plegia dependent  on  gross  nervous  lesions.  It  should 
however  be  recollected  that  hysterical  people  are  subject, 
like  other  mortals,  to  diseases  which  bear  no  relation  to 
their  nervous  trouble. 

Treatment.  A  protest  must  be  entered  against  the  cruel 
indifference  with  which  the  ever  returning  ills  and 
ailments  of  the  hysterical  are  generally  regarded.  The 
physician  who  shares  this  error  is  certainly  blamable. 
Banter  and  ridicule  are  entirely  out  of  place.  Hysteria 
is  not  a  dangerous  malady,  it  does  not  kill,  but  it  is  a 
most  distressing  affliction.  To  deal  with  it  successfully 
requires  a  tact  on  the  part  of  the  physician,  w^hich  not 
every  one  has  at  command.  If  he  succeeds  in  gaining 
the  confidence  of  the  patient,  which  is  best  accomplished 
by  unaffected  sympathy  combined  with  firmness  he  will 
have  a  comparatively  easy  task  before  him. 

Moral  therapeutics  therefore  takes  the  first  rank  in  the 
treatment  of  hysteria.  Seeing  that  mental  excitement  is 
often  the  vera  causa  of  the  most  severe  forms  of  the  disorder, 


e04  MAX  UAL   OF  XERVOCS  DISEASES. 

such  prophylactic  measures  should  be  recommended  that 
guard  against  the  influences  which  develop  and  keep  up 
hysterical  manifestations.  In  the  management  of  invet- 
erate cases  it  may  become  necessary  to  change  the  sur- 
roundings of  the  patient  and  to  secure  rest  by  seclusion 
in  which  a  rational  treatment  can  be  systematically 
carried  out. 

Some  of  the  popular  measures  for  cutting  short  a  hys- 
terical fit  are  often  quite  effectual,  but  stuffing  the  mouth 
with  salt  or  throwing  a  pailful  of  water  over  the  head  of 
the  patient  should  not  have  the  sanction  of  the  physician. 
It  will  suffice  to  splash  some  cold  water  in  the  face,  or  if 
the  patient  is  ver\^  violent  to  irrigate  the  head  for  a  few 
minutes  at  a  time.  Severe  measures  are  at  any  rate  not 
called  for  in  a  disorder  which  ceases  of  its  own  accord 
and  is  unattended  with  danger.  What  may  be  called 
'•habitual  hysterical  fits"  are  best  controlled  by  stern 
reproof.  Firm  pressure  in  the  region  of  the  hyperses- 
thetic  ovary  sometimes  succeeds  in  checking  an  attack. 
Hysterical  paralysis  yields  better  to  moral  treatment, 
when  conducted  with  tact  and  perseverance,  than  to  any 
other  measure.  The  patient  is  to  be  persuaded  to  make 
at  least  some  effort  to  overcome  her  muscular  weakness. 
An  intelligent  nurse  can  be  of  far  more  assistance  than 
any  one  of  the  family  of  the  patient.  As  soon  as  the 
patient  has  gained  some  confidence  in  her  ability  to  help 
herself,  improvement  will  soon  follow.  This  treatment 
can  be  advantageously  aided  by  electricity,  massage  and 
cold  douches  to  the  spine. 

Hysterical  aphonia  is  often  successfully  treated  by 
electricity.     The  electrodes  of  a  galvanic  current  are   to 


HYSTERIA.  295 

be  placed  to  the  sides  of  the  neck,  or  Mackenzie's  elec- 
trode is  introduced  into  the  larynx. 

Gynecologists  claim  good  results  in  hysteria  from  the 
treatment  of  uterine  disturbances.  It  may  readily  be 
admitted  that  benefit  has  been  derived  from  correcting  a 
displaced  uterus,  or  from  the  relief  of  ovarian  trouble, 
but  in  numerous  cases  such  treatment  has  utterly  failed 
to  cure  the  hysteria. 

The  employment  of  remedies  against  the  multitude  of 
nervous  disorders  in  pronounced  hysteria  is  a  thankless 
task.  But  even  under  the  unpromising  condition  of  hav- 
ing to  deal  with  a  constitutional  diathesis,  the  physician 
can  be  of  great  service  to  his  patient  if  he  succeeds  in 
inspiring  confidence  in  his  eff'ort  to  aftbrd  relief.  The 
effects  of  moral  therapeutics  is  sometimes  seen  in  the 
"cures"  from  some  highly  advertised  "infallible  remedy," 
or  the  passes  and  manipulations  of  the  "electro- 
magnetizer." 

In  cases  associated  with  anaemia  or  a  decline  of  the 
general  health  a  tonic  and  an  invigorating  treatment  is 
indicated.  Cold  baths  and  douches  and  general  galvani- 
zation will  often  be  found  of  service. 

Among  the  "  anti-hysterical  "  remedies  it  is  only  vale- 
rian that  sustains  some  sort  of  reputation,  because  it  is 
not  quite  as  offensive  as  assafoetida.  The  bromides  are 
sometimes  very  useful.  Narcotics  should  be  sparingly 
given,  or  better  not  at  all  if  not  urgently  called  for. 
Paraldehyde  from  5ss  to  5i  is  occasionally  quite  effective 
in  calming  hysterical  excitement.  Hemiana^sthesia  is 
best  treated  with  the  faradic  brush. 


296  MAXCAL   OF  NERVOUS  DISEASES. 

HYPOCHONDRIASIS. 

Etiology.  Hypochondriasis  chiefly  affects  men,  but 
typical  examj^les  of  the  malady  are  occasionally  observed 
in  women.  It  is  always  a  chronic  affection,  though  it 
never  endangers  life.  Apparently  there  seems  to  he  an 
affinity  between  hypochondriasis  and  melancholia,  inas- 
much as  the  alteration  common  to  both  is  characterized 
by  a  depressed  mental  condition,  but  it  would  be  errone- 
ous to  class  hypochondriasis  with  insanity,  for  the  intelli- 
gence remains  clear  in  the  former,  and  it  is  only  an 
excessive  anxiety  and  apprehension  manifested  by  the 
hypochondriac  in  regard  to  his  ill-defined  symptoms 
which  develop  his  fanciful  notions. 

Clinical  history.  The  essential  clinical  feature  of  hypo- 
chondriasis is  a  morbid  disposition  to  fix  the  attention  on 
slight  ailments,  which  are  magnified  and  falsely  inter- 
preted by  the  patient.  The  anomalous  sensations  of 
which  he  constantly  complains  are  undoubtedly  real; 
they  absorb  his  thoughts,  leave  him  no  rest,  and  render 
him  sad  and  peevish.  Besides  these  indistinct  sensations, 
which  probably  originate  in  the  abdominal  viscera,  there 
are  other  symptoms  of  a  more  palpable  nature.  They 
chiefly  consist  of  an  uneasiness  felt  in  the  epigastric 
region,  a  burning  sensation  about  the  umbilicus,  flatu- 
lence, disordered  bowels,  palpitations,  flushes  of  heat  in 
the  face  and  frontal  headache.  Each  of  these  morbid 
sensations,  as  they  more  or  less  bother  the  patient,  is  a 
source  of  alarm  to  him.  He  watches,  studies  and  bewails 
them.  By  and  by  he  locates  them  in  a  particular  organ 
or  some  part  of  the  body,  and  becomes  convinced  that  he 
is  the  victim  of  a  serious  disease.     The  shifting  character 


HYPOCHONDRIASIS.  297 

of  the  vague  feelings  is  probably  the  reason  why  hypo- 
chondriacs imagine  they  are  successively  affected  by  a 
variety  of  diseases.  Now  it  is  the  stomach,  then  the 
liver,  next  the  heart,  the  lungs,  the  bowels,  the  bladder, 
the  rectum  or  spinal  marrow.  This  change  in  the  situ- 
ation of  the  fancied  disorder  is  often  suggested  by  the 
names  of  diseases  about  which  these  patients  hear  or 
read.  They  continually  change  their  medical  advisers 
and  are  voracious  consumers  of  drugs.  Some  are  in 
fear  of  losing  their  sexual  power,  and  if  ever  they  have 
had  syphilis  or  imagine  they  had  it,  become  confirmed 
syphilophobes. 

Treatment.  Although  hypochondriac  people  are  exceed- 
ingly fond  of  taking  medicines  and  sometimes  declare 
they  are  benefited,  yet  they  never  acknowledge  a  cure- 
There  is  no  use  to  direct  treatment  against  any  special 
symptom,  for  ten  others  will  take  its  place.  Attention 
should  nevertheless  be  paid  to  the  digestive  organs,  which 
are  frequently  disordered.  Vegetable  tonics,  such  as 
calisaya  bark,  cascarilla,  columbo  and  gentian,  with  the 
addition  of  a  mineral  acid,  answer  very  well.  As  torpidity 
of  the  bowels  is  a  standing  complaint  of  these  patients,  it 
is  advisable  to  prescribe  an  occasional  pill  of  aloes  and 
nux  vomica,  or  the  compound  liquorice  powder  if  hemor- 
rhoids exist.  An  active  life,  devoted  to  a  regular  occu- 
pation which  involves  considerable  physical  exertion,  is 
often  of  greater  service  than  all  medication.  Good  results 
are  occasionally  obtained  from  "moral  therapeutics." 
An  effort  may  be  made  to  wean  the  patient  from  his 
gloomy  thoughts  and  brooding  over  his  ailments.  Accord- 
ing to  circumstances,  he  may  be  urged  to  enter  a  political 
career,    or   take   an  interest   in  a  popular   philanthropic 


S9S  MA  N  UAL   OF  NER  VO  US  D  IS  EA  SES . 

cause,  attend  to  vestry  meetings,  engage  in  a  scientific 
pursuit,  or  cultivate  one  of  the  fine  arts.  Extensive 
traveling,  which  breaks  in  upon  the  monotonous  routine 
of  life,  is  sometimes  beneficial.  Such  strategy  has  in 
some  instances  proved  successful. 

Griesinger  relates  the  case  of  a  young  woman  who 
fancied  that  her  intestines  protruded  through  the  partly 
opened  abdominal  walls.  Her  physician  did  not  dispute 
this,  but  told  her  that  it  is  not  unusual  for  the  abdominal 
muscles,  when  they  are  Aveak,  to  permit  the  intestines  to 
come  to  the  surface.  He  ordered  an  api>aratus  to  support 
the  parts,  and  had  the  satisfaction  by  these  means  not 
only  to  cure  her  of  her  f^lse  idea,  but  also  relieved  the 
constipation  of  the  bowels,  from  which  she  had  suff'ered 
for  a  long  period. 


CHAPTER  XVI. 

PARETIC  DEMENTIA. 

(General  Paresis  of  the  Insane.) 

It  is  of  great  practical  importance  to  the  general 
physician  to  be  familiar  with  the  peculiarities  of  this 
disease,  which,  under  the  disguise  of  mental  weakness 
and  alteration  of  the  moral  tone,  affects  individuals  in 
the  prime  of  life,  and  tends  to  progressive  deterioration 
of  both  body  and  mind.  Outside  of  the  profession  the 
fully  established  disease  is  called  by  the  ominous  name 
of  "softening  of  the  brain." 

Etiology.  Paretic  dementia  makes  the  heaviest  inroads 
among  those  classes  of  society  where  the  feverish  activity 
of  modern  civilization  is  conspicuous.  The  disease  attacks 
men  between  the  ages  of  thirty  and  forty  years.  Women 
are  much  less  liable  to  be  affected.  A  hereditary  ten- 
dency if  at  all  existing  is  not  evident.  Of  greater  etio- 
logical importance  is  the  connection  of  a  history  of 
syphilis  with  a  large  proportion  of  cases.  It  is  a  signifi- 
cant fact  that  the  disease  mostly  occurs  in  men  living  in 
large  cities.  Its  victims  constitute  a  high  percentage  of 
the  inmates  of  our  insane  asylums. 

Clinical  History.  Certain  periods  may  be  distinguished 
in  the  course  of  paretic  dementia  which  mark  its  several 
stages,  but  the  order  of  occurrence  of  the  essential  symp- 
toms in  numerous  cases  is  too  variable  to  permit  of  such 

(  290  ) 


SOO  MA  X  UAL   OF  N  EEVOUS  DISEA  S'ES . 

a  strict  division  of  its  clinical  history.  The  simultaneous 
and  successive  pathological  changes  of  important  nerve 
centers  give  rise  to  psychical,  motor  and  sensory  disturb- 
ances that  observe  no  uniformity  of  development.  Never- 
theless a  typical  case  presents  ample  diagnostic  points. 

The  disease  always  begins  with  a  precursory  stage. 
Prodromic  symptoms  develop  so  insidiously  that  often  no 
satisfactory  information  can  be  obtained  in  regard  to  the 
time  when  they  lirst  attracted  notice.  The  condition  of 
impaired  mental  capacity  is  chiefly  manifested  by  a  com- 
mencing failure  of  the  memor}^  and  laxity  of  the  moral 
sense.  This  alteration  is  a  puzzle  to  the  family  and 
associates  of  the  patient.  He  exhibits  an  unusual  levity? 
neglects  his  business,  becomes  fond  of  spirituous  liquors, 
visits  disreputable  houses  and  gives  various  indications 
of  changed  habits.  He  mislays  valuable  papers,  is 
inattentive  to  important  appointments,  gives  orders  to  his 
assistants  which  he  forgets  and  thus  disarranges  his 
affairs.  Delinquencies  of  which  he  is  guilty  at  this 
period  are  partly  due  to  his  thoughtlessness  and  partly 
to  his  moral  debasement.  He  may  for  this  reason  com- 
mit a  theft  or  forge  a  check  with  little  compunction.  The 
sedate  paterfamilias  shocks  by  his  loose  language  and 
rakish  demeanor.  The  promising  young  man  violates 
the  ordinaryirules  of  propriety  and  decorum.  He  enters 
a  course  of  alcoholic  and  sexual  excess.  If  he  is 
reproached  for  his  conduct  he  takes  little  pain  to  set 
himself  right,  or  offers  some  unplausable  reason  in 
extenuation. 

The  paretic  dement  is  generally  intolerant  of  contra- 
diction, flies  into  a  passion  about  trifles,  but  shows  a 
remarkable  equanimity  at  the  miscarriage  of  his  affairs. 


PARETIC  DEMENTIA.  301 

He  engages  in  foolish  and  ruinous  enterprises,  spends  his 
money  lavishly,  and  readily  enters  into  objectionable 
matrimonial  alliances.  It  would  be  difficult  to  prove 
that  such  a  person  is  insane,  but  he  is  certainly  fast 
drifting  into  it. 

Symptoms  of  a  different  order  frequently  make  their 
appearance  during  this  period.  The  patient  is  troubled 
with  headache,  dizziness,  momentary  confusion  of  the 
mind  and  a  feeling  of  general  illness.  He  becomes 
alarmed  concerning  the  state  of  his  health  and  is 
vaguely  conscious  of  some  deterioration  of  his  former 
mental  capacity.  He  is  depressed,  emotional,  or  a  true 
melancholia  develops.  The  physician,  who  is  consulted 
at  this  stage  would  probably  misinterpret  the  symptoms, 
if  the  family,  who  know  more  about  the  condition  of  the 
patient  did  not  give  the  proper  information. 

The  development  of  very  marked  psychical  and  somatic 
symptoms  may  be  considered  the  second  stage.  A  close 
examination  might  have  noticed  before  this  a  peculiar 
defect  of  speech,  but  this  symptom  is  now  more  apparent. 
A  tremulous  movement  of  the  lips  and  tongue  attends 
the  utterance  of  words,  as  if  they  had  to  overcome  an 
impediment:  the  words  come  out  with  an  explosion. 
The  brow  corrugates,  the  zygomatic  muscles  are  fixed, 
the  nostrils  alternately  contract  and  dilate.  Very  char- 
acteristic are  the  patient's  blunders  in  pronouncing  diffi- 
cult words,  as  "artrallirary"  for  artillery,  "cletircal"  for 
electrical.  He  makes  use  of  wrong  words.  His  hand- 
writing has  also  deteriorated.  It  is  coarse  and  does  not 
keep  to  the  line,  single  letters  and  whole  syllables  are 
omitted.  A  similar  incoordination  affects  his  hands  and 
fingers,  especially  noticeable  in  mechanical  employments. 


302  MA  K  UAL   OF  XEB  VO  US   DISEASES. 

If  the  patient  is  an  artist,  he  has  lost  nicety  and  deli- 
cacy of  touch.  There  is  an  unsteadiness  of  the  gait.  The 
patient  throws  his  limbs  too  Avide  apart.  Dancing,  skat- 
ing, swimming  and  the  like  accomplishments  are  awk- 
wardly performed,  or  no  longer  practicable.  If  the  patient 
is  tested  in  reckoning  or  in  drawing  up  accounts  his 
lapses  and  glaring  mistakes  are  of  diagnostic  value. 

Pupillary  changes  or  paralysis  of  external  ocular 
muscles  constitute  significant  initial  symptoms.  They 
are  rarely  absent  in  advanced  cases.  Inequality  of  the 
pupils  or  reflex  immobility  (Argyle  Robertson  pupil)  and 
ptosis  are  often  observed. 

If  in  connection  wath  the  symptoms  that  have  been 
described,  there  is  loss  of  the  patellar  reflex,  migraine, 
and  neuralgia  of  the  extremities,  the  co-existence  of  loco- 
motor ataxia  may  be  suspected. 

As  the  mental  alienation  progresses,  there  is  a  devel- 
op n:ient  of  expansive  delusions  and  extravagant  pro- 
jects corresponding  to  fancies  of  exaltation  and  grandeur. 
This  character  of  the  delusions  is  not  peculiar  to  general 
paresis,  but  is  observed  in  this  disease  with  great  fre- 
quency and  distinguished  by  an  absurdity  that  overleaps 
all  bounds  of  the  possible.  The  monomaniac  may  fancy 
that  he  is  a  king,  an  apostle,  or  a  millionaire  :  he  acts 
the  assumed  role  and  maintains  his  pretensions  against 
all  comers.  But  the  paralytic  dement  declares  that  he  is 
King  of  all  Kings,  the  possessor  of  all  the  gold  mines  in 
the  world,  Napoleon,  or  God  Himself — all  in  one  breath. 
He  is  never  struck  by  the  bare  incongruity  of  these  fic- 
tions, personates  them  but  indifferently  and  is  easily  per- 
suaded   to  drop  them  —  though  only  to  take  up  others 


PARETIC  DEMENTIA.  SOS 

just  as  senseless  and  ridiculous.  Even  when  melancholia 
tinges  the  delusions,  they  partake  of  the  absurd.  Such 
a  patient  may  say  that  he  only  measures  an  inch  in 
height,  that  he  is  three-cornered  and  died  yesterday.  The 
delusions  of  the  female  paretic  turn  upon  matters  con- 
genial to  her  sex.  She  boasts  of  possessing  thousands  of 
silk  dresses,  is  confined  with  twins  every  day  and  the  like. 

The  paretic  dement  not  only  braggs  of  his  enormous 
w^ealth  and  high  distinction,  but  also  of  his  muscular 
strength  and  fabulous  sexual  power.  He  can  lift  the 
roof  off  the  building  with  the  greatest  ease  ;  he  has 
married  the  finest  women  in  town  and  his  genital  is  two 
feet  long.  Erotic  delusions  are  particularly  common  in 
male  patients.  The  subjective  feeling  of  an  exuberance 
of  health  and  well-being  is  another  of  the  marked  features 
of  the  disease.  If  the  paretic  dement  is  asked  how  he 
feels — he  answers  "first-rate,"  "  never  felt  better  in  his 
life,"  he  is  'all  right."  Generally  he  is  good-humored 
and  cheerful  and  appears  to  be  one  of  the  happiest 
mortals.  Some  are,  however,  ill-natured  and  occasionally 
combative.  The  position  in  life  and  education  of  the 
patient  modifies  the  delusions.  A  driver  of  a  furniture 
wagon,  whom  I  examined  before  his  admission  into  the 
hospital,  told  me  that  his  credit  at  the  Savings  Bank 
would  keep  him  and  his  family  for  ten  life-times,  and 
then  related  with  great  gusto,  how  he  "used  up"  a  man 
with  whom  he  had  had  a  quarrel.  This  tendency  to  give 
revolting  details  of  imaginary  encounters  has  often  been 
noticed  in  the  paretic  dement. 

The  extravagant  projects  of  patients  frequently  involve 
delusions  of  ludicrous  and  impossible  schemes  of  amassing 
untold  wealth. 


304  JIAXUAL  OF  NERVOUS  DISEASES. 

Paroxysmal  attacks  of  mania  and  epileptoid  and 
apoplectiform  seizures  constitute  notable  features  of  the 
disease. 

The  maniacal  paroxysms  generally  develop  at  a  late 
period,  and  sometimes  even  at  an  early  date.  In  very  rare 
cases,  they  are  nearly  continuous  and  may  prove  fatal  from 
nervous  exhaustion,  but  usually  they  resemble  acute 
delirium.  The  mental  excitement  in  many  cases  is  that 
of  simple  mania,  of  a  violent,  outrageous  and  malevolent 
character.  Patients  sing,  shout  and  are  destructive.  They 
are  filthy,  constantly  spit  and  besmear  themselves  with 
their  excrements.  In  their  imbecile  fury  they  make 
desperate  assaults,  and  are  considered  the  most  trouble- 
some inmates  of  asylums.  Their  brutality  is  sometimes 
exhibited  in  outbreaks  after  release  from  their  confine- 
ment. They  use  violent  and  abusive  language  and 
threaten  those  who  had  a  hand  in  their  incarceration 
with  cruel  penalties.  A  maniacal  paroxysm  may  last 
for  hours  or  days  and  is  succeeded  by  a  brief  stupor. 

Epileptoid  attacks^  appear  towards  the  termination  of  the 
disease.  Usually  the  spasms  are  unilateral  and  rarely 
present  the  violence  of  a  true  epileptic  fit.  A  patient 
often  remains  in  this  condition  for  days  and  recovers  from 
it.     Consciousness  is  not  always  impaired. 

Apoplectiform  attacks  like  the  epileptoid  seizures  occur 
towards  the  close  of  the  disease,  though  in  some  cases 
they  are  witnessed  at  an  early  period.  The  sudden  loss 
of  consciousness  may  happen  whilst  the  patient  is  engaged 
in  conversation.  The  head  is  hot  and  the  face  flushed 
like  in  cerebral  hyperemia.  But  apoplexy  from  cere- 
bral hemorrhage  may  also  occur  and  prove  fatal.  I  once 
attended  a  man  who  had  apparently  improved  after  hav- 


PARETIC  D EMEN TIA.  305 

ing  exhibited  unmistakable  symptoms  of  paretic  demen- 
tia. He  became  a  frequent  visitor  of  restaurants  and 
club-rooms,  from  which  places  he  was  several  times 
carried  home  in  a  condition  of  congestive  apoplexy.  He 
died  eighteen  hours  after  the  last  seizure  during  which 
time  he  did  not  recover  his  consciousness.  Although 
patients  usually  get  over  these  episodical  attacks  of 
mania  and  epileptoid  and  apo23lectiform  seizures,  they 
constantly  lose  ground  after  each  attack. 

Before  the  last  stage  of  the  disease  is  reached,  very 
remarkable  remissions  of  prominent  symptoms  are 
occasionally  witnessed.  Improvement  may  be  so  evident, 
that  the  family  of  the  patient  conclude  to  remove  him 
from  the  asylum  under  the  impression  that  complete 
recovery  has  taken  place.  Such  a  patient  may  again  ])e 
capable  of  attending  to  ordinary  affairs  and  enjoy  the 
liberty  and  comforts  of  home.  But  experience  has  taught 
that  relapses  are  common,  and  that  these  invalids  are 
not  only  liable  to  give  way  when  undertaking  the  man- 
agement of  complicated  transactions,  but  are  apt  to 
become  involved  in  enterprises  that  may  sink  a  fortune. 

The  downward  tendency  of  the  disease  is  marked  by 
progressive  obscuration  of  the  intelligence  and  continued 
increase  of  the  paretic  condition,  until  the  patient  is 
reduced  to  an  utter  wreck  of  body  and  mind.  When 
this  third  and  last  stage  is  reached  he  may  be  carried  off 
in  a  few  months  by  the  "  galloping"  form  of  the  disease. 
The  fatal  termination  is  sometimes  postponed  for  two  or 
three  years.  Death  is  often  hastened  by  the  development 
of  malignant  decubitus. 

Anatomical  Changes.  Very  marked  post-mortem  appear- 
ances  are   found    in   subjects,    who    have   died   in    the 

20 


S06  MA  NUAL  OF  NER  VO  US  D  IS  EA  S  ES . 

advanced  stage  of  the  disease.  Symmetrical  parts  of  the 
brain  and  spinal  cord  are  involved  in  a  degenerative 
process,  that  probably  originated  in  a  low  inflammation. 
The  sknll  in  many  places  is  thickened.  Bony  plates  are 
sometimes  found  in  the  adherent  dura  mater.  Hemor- 
rhagic pacchymeningitis  quite  often  exists.  Some  por- 
tions of  the  brain  are  entirely  atrophied,  leaving  gaps 
between  the  unaffected  parts.  Cortical  areas  are  slightly 
softened  or  indurated.  The  ganglion  cells  in  these  regions 
show  marked  degeneration.  A  cystic  formation  is  very 
frequently  noticed,  consisting  of  minute  cavities,  which 
are  due  to  dilatation  of  perivascular  spaces  in  the  gray 
and  white  substance.  The  basilar  portion  of  the  brain  is 
affected  to  a  much  less  extent  than  the  convexity,  but 
the  pons  and  the  medulla  show  partial  atrophy.  The 
axis  cylinders  of  the  nerve  fibres  are  coarse  and  dis- 
tended. Very  decided  changes  are  constantly  found  in 
the  neuroglia,  from  slight  increase  of  connective  tissue  to 
complete  sclerosis.  The  blood-vessels  of  the  affected  parts 
are  twisted  and  tortuous.  The  adventitia  and  the  mus- 
cular coat  have  undergone  degeneration.  To  this  condi- 
tion of  the  vessels  must  be  attributed  the  venous  stasis 
and  thrombic  coagulations  in  the  substance  of  the  brain. 
Nuclear  or  "  free  bodies"  are  seen  in  the  lymph  spaces, 
some  of  which  are  transformed  into  spider  cells.  Analogous 
changes  are  found  in  the  spinal  cord.  The  adhesions  of 
the  arachnoid  and  dura  mater  to  the  subjacent  parts  of 
the  cord  present  the  appearance  of  a  meningo-myelitis. 
A  fascicular  degeneration  often  involves  the  posterior 
columns  as  in  loco-motor  ataxia.  Sometimes  the  sclerosis 
is  diffuse  and  has  implicated  the  cells  of  the  anterior 
cornua, 


PARETIC  DEMENTIA.  307 

The  gross  changes  in  the  brain  and  the  spinal  cord 
explain  the  general  nature  of  the  symptoms,  but  what 
can  be  said  in  regard  to  those  cases  of  the  disease,  in 
which  no  such  morbid  alterations  are  found.  It  has  been 
suggested,  that  disturbance  of  the  cerebral  circulation 
initiated  by  vaso-motor  influences  which  leave  no  traces, 
originates  the  symptoms,  and  that  the  degeneration  of 
important  nerve-centers  takes  place  in  the  more  advanced 
cases  of  the  disease. 

Diagnosis.  In  the  matter  of  diagnosis  the  great  practical 
importance  of  recognizing  the  early  signs  of  the  disease 
is  evident.  Alteration  of  the  mental  condition,  espe- 
cially on  the  moral  side  is  significant.  It  is  not  usual 
for  a  man  of  settled  habits  of  life  to  change  them.  The 
evidences  of  such  a  change  vary  in  different  individuals, 
but  they  all  indicate  the  complication  of  an  enfeebled 
memory,  shallow  reasoning,  moral  laxity  and  weakness 
of  the  will.  Palpable  errors  in  reckoning,  a  deteriorated 
hand-writing,  tremulous  lips  in  the  act  of  speaking  and 
pupillary  changes  are  valuable  diagnostic  points.  Of 
much  importance  are  the  episodical  paroxysms  of  mania 
and  the  epileptoid  and  apoplectiform  attacks.  Usually 
the  diagnosis  of  a  typical  case  of  paretic  dementia 
causes  no  embarrassment.  Uncertainty  will  be  felt  in 
cases  resembling  ordinary  mania,  brain  tumor,  cerebral 
syphilis  and  especially  atypical  examples  of  multiple 
sclerosis. 

Tlie  Prognosis  is  exceedingly  unfavorable.  Cases  of  recov- 
ery do  occur,  but  hundreds  of  demented  paralytics  die 
yearly  in  our  hospitals. 

Treatment.  Therapeutics  holds  out  but  faint  hopes  in  a 
disease    dependent   on    destroying   lesions   of  important 


SOS  MANUAL   OF  NERVOUS  DISEASES. 

nerve  centers.  In  the  early  stage  it  may  be  possible  to 
arrest  the  disease  in  some  cases,  and  the  effects  of  iodide 
of  potassium  should  at  least  be  fairly  tested.  Alcoholic 
stimulants  and  sexual  excesses  should  be  strictly  pro- 
hibited. Above  all,  it  is  the  bounden  duty  of  the  attend- 
ing physician  to  apprise  the  family  or  friends  of  the 
patient  of  the  true  state  of  the  case,  and  of  the  risk  he 
runs  of  raising  scandal  and  effecting  his  pecuniary  ruin, 
if  the  proper  precautions  be  not  taken.  There  should 
be  no  hesitation  to  recommend  the  seclusion  and  care  of 
an  asylum  as  soon  as  the  disease  is  recognized.  The 
prompt  and  systematic  treatment  at  an  early  period  in 
such  an  establishment  offers  the  best  chance  of  benefit- 
ing the  patient. 


BIBLIOGRAPHY. 


Arndt.     Die  Neurastlienie. 

Bastian.     On  Paralysis  from  brain  disease. 

Beard.     jSJervous  Exhaustion. 

Rroadbent.     Transactions. 

Charcot.     Diseases  of  the  brain  and  spinal  cord. 

Dalton.    Topographical  anatomy  of  the  brain. 

DowsK.     On  Neuralgia. 

EcKEK.     Die  Gehirnwindungen  des  Menschen. 

Ekb.     Electrotherapie. 

EscHEVERRiA.      Epilepsy. 

Ferrier.     Functions  of  the  brain. 

Flechsig.     Die  Lietungsbahnen  in  Gehirn  and  Riickenmarks  des 

Menschen 
Gowers.     Diseases  of  the  brain  and  spinal  cord.     Epilepsy. 
Hammond.     On  nervous  system. 
Hamilton.     On  nervous  diseases. 
Jackson,  H.     Clinical  and  physiological  researches  of  the  nervous 

system. 
Jacobi.     Hysteria  and  brain  tumor. 
LiDDEL.     Apoplexy  and  cerebral  affections. 
MiTCHEL  S.  Weir.     Lectures  on  diseases  of  the  nervous  system, 

especially  in  women. 
Meynert.     Strieker's  Histology. 
MuNK.     Verhandlungen    der    physiologischen     Gesselschaft    zu 

Berlin. 
Nothnagel.     Gehirnkrankheiten. 
PuTZEL.     Functional  nervous  diseases. 
Rannev.     The  applied  anatomy  of  the  nervous  system. 
RocKWELT-.    Electricity. 
Rosenthal.     Diseases  of  the  nervous  system. 

( m ) 


310  MA  N UAL  OF  NER  VO  US  D IS EA  SES . 

Ross.     Nervous  diseases. 

Seguin.     Spinal  paralysis. 

Seligmuller.     Nervenkrankheiten. 

Spitzka.     Manual  of  insanity. 

Starr.     Cortical  lesions  of  the  brain.     Am.  Jour.  Med.  Sci. 

Strumpel.    Text-book  of  medicine. 

Trosseau.     Clinical  medicine. 

TuKE.     Influence  of  the  mind  on  the  body. 

Vulpian.     L'appareil  vaso — moteur. 

Webber.     Nervous  diseases. 

Wernicke.     Lehrbuch  der  Gehirnkrankheiten. 

Wood,     H.  C.     Nervous  diseases. 

ZiEMSSEN.     Encyclopedia  of  practical  medicine,  vol.  xiv. 


FORMULAE 


Hypodermics.  Tablets  of  morphia  gr.  i  to  \  and  of  atropia  gr. 
T2  0  to  eV  are  now  conveniently  employed  for  hypodermic  injections. 
They  readily  dissolve  in  water.  Magendie's  solution  of  morphia 
containing  one  grain  in  30  minims  is  also  well  adapted  for  hypo- 
dermic use. 

The  cerebral  effect  of  morphia  is  antagonized  by  combining  it 
with  atropia.  Tablets  containing  the  proper  proportions  of 
these  remedies  are  now  offered  for  sale  by  reliable  druggists.  The 
following  formulae  are  recommended  : 

^    Morphias  Sulphatis      -        -        -      gr.  vi 
Atropine  Sulphatis   -        -        -         ^t.  I 
Aquae  Destillatte  -        -        -      5  ss  M 

Sig.    Inject  10  M.  or  more  according  to  circum- 
stances. 


^ 

btrychnue          ...         -          gr.  1 

Aquae  Destillatae           -        -        -      5  ss  M 

Sig.    Inject  from  5  to  10  minims. 

^ 

Codeiae gr.  iv 

Aquae  DestillatcC    -        -        -        -    5  ss  M 
Sig.     Inject  M  xxx 

Headaclie. 

^ 

Antipyrini     -        -        -        -        -    9  ij 

Insomnia. 

Ft.  in  capsulas  no.  iv 
Sig.  one  every  3  hours  or  one  &t  bedtime, 
or 

(311) 


312  MANUAL  OF  NERVOUS  DISEASES. 

HeadaClie.       9^    Autipyrini 5  ii 

InsOMia.  Syr.  Aurantite  cort.  -        -        -  5  ss 

Aquse  Aurantifc  flor.  ad       -        -      5  ij      M 

Sig.     A    dessert   spoonful    every  one  or  two 

hours  until  three  to  six  doses  are  taken. 


Tinct.  Cannabis  Indic?e     - 

gtt.  XV 

Chloral  Hydratis 

gr.  X 

Potass.  Bromid. 

gr.  XX 

Elix.  Smpl.           .... 

5i     M 

Sig.    Take  before  going  to  bed. 

Heiiucrania. 

Tinct.  Cannabis  [ndicfe    - 

gtt.  X 

Eth.  Sulph. 

■    gtt.  xxiv  M 

Sig.     Take  in  a  tablespoonful  of  water. 

V^    Urethani gr.  viii 

Confect.  Rosa^         -        -        -        -  gr.  xv     M 

Ft.  massa  et.  in  pil.  No.  xxiv  div. 

Sig.     From  one  to  three  pills. 

Insomnia. 

9=  Paraldehydi  -  -  -  -  oi'i 
Alcohol  is  ....  -  ^^iss 
Spir.  Lavandul.  Comp.     -  -        '^\\ 

Syr.  Smplicis      -        -        -        ad     ^iv         M 
Sig.     One  dessertspoonful  every  hour  until 
sleep  is  produced. 

9;    Sulfonali gr  xx— xxx 

Sig.     Take  in  black  coffee  or  in  syr.  aurant. 

Insomnia. 

T^    Camphor  Monobromatis      -        -       9  i 

Make  into  10  pills  covered  with  gelatine. 
Sig.     Take  one  or  two  pills  every  two  hours. 


FORMULAE.  3U 

Headache.       V^    Caffein  Citratis  ...         5  gg 

iDSOmnia.  Syr.  Limonis         -        -        -        -       S  ss 

Aqu?e  -        -        -        -         ad      g  ii  M 

Sig.     One    teaspoonful  every    three  hours. 

9^    Efferv.  Brorao-CafFeini 

Sig.     One  teaspoonful  in  a  wineglassful  of  water 
every  hour  or  two. 

9     Guaranie gr.  x— xx 

Pulv.  i\romat    -        -      .      -        -    gr.  v 
Sig.     Take  every  2  hours  until  relieved. 

Hemicrania. 

^    Phenacetini    -        -        -        -  gr.  iii 

CafFein  Citratis  ...  gr.  iss 

Sacch.  Lacti        -        -        -        -      gr.  v    M 
Sig.     Take  every  two  hours  until  the  head- 
ache is  relieved. 

^    Tinct.  Opii  Deodorat    -        -        -     gtt.  xxx 
Tinct.  Digitalis    -        -       -       -        gtt.  x     M 

Cerehral  Congestion 

^    Pulv.  Opii         -        -        -        -        gr.  i 

Quinifp         .        -        -  -  gr.  iii     M 

Make  into  two  pills. 
Cerebral  Anxmia. 

1^    Ext.  fl.  Conii        -        -        -  M  xx 

Sig.     At  one  dose  to  be  followed  by  from  five  to 

ten  minims  every  hour  until  the  excitement  is 

subdued. 

Mai. iacal  Excitement. 

9    Chloral.  Hydratis 

Potass.  Bromidi        -        -         aa     5  ^^    ^ 
(One  full  dose  acts  better  than  frequent  small 
doses.) 


314  MA  N  UA  L   O  F  KEB  V  OUS  DI S  EA  SES . 

Headaclie,       ^     Ammonii  Chioridi       -        -      -  3  iii 

InSOinia.  Morphia-  Acet.        -        -        -  gr.  i 

Caffein.  Citratis    -       -        -        -  5  ss 

Spirt.  Ammonite  Aromat        -  5  i 

Elix.  Guarana?    -        -        -        -  '!^  iv 

Aqua-  Roste    -        -        -        -  5  i^'    ^^ 

Sig.     One    dessertspoonful    every  quarter 
hour  until  relieved. 

Bilious  headache  after  debauch. 

Debout's  Pills. 
^    Quinine  Sulphatis    -        -        -  5  i 

Pulv.  Digitalis      -        -        -        -      gr.  viii 

Make  into  twenty  pills. 
Sig.     One  every  four  hours. 

Neuralgia.       ^    Quiniae  Sulphatis        -        -         -      5  i 
Morphise  Sulphatis        -        -        -    gr.  ii 

Ft.  massa  in  pill  No.  xxx  div. 
Sig.     One  pill  thrice  daily  and  gradually  in- 
creased until  nine  are  taken. 

J^    Quiniae  Sulphatis        -        -  -      5  i 

Morphiae  Sulphatis 
Acid  Arseniosi    -        -        -         aa    gr.  iss 

Ft.  massa  in  pill  No.  xxx  div. 
Sig.     Taken  as  the  foregoing. 

^    Fl.  Ext.  Gelsemini 

"      "     Black  Cohosh        -        aa     ."^  i       M 

Sig.  Four  drops  every  hour.  The  dose 
should  be  diminished  if  drooping  of  the 
eyelids  is  noticed. 

^     Exalgina'     -----      gr.  vtox 

Taken  in  capsule. 


FORMULJE.  315 

Borson's  Pills. 
Neuralgia.      9=    PuIv.  Moschi        -        -  -  gr.  x 

Pulv.  Digitalis    -      -        -        -         gr.  v 

Opii        -        -        -        -        -      -       gr.  iv 

Make  into  ten  pills. 
Sig.     One  every  four  hours. 

9;    Acomiuii  {Duquesnill)     -         -  ^Y.^^io\ 
Glyeerina? 

Alcoholi   -        -        -        -    aa  3  i 

Aqua  Mentlue  pip     q.  s.  ad  5  ii     M 

Sig.     One  teaspoonful   two    or  three  times 
a  day. 

Facial  Neuralgia. 

(i     Phenacetini      -        -        -        -         gr.  x 

In  capsule. 
Sig.     P^very  hour  until  relieved. 

1^     Antipyrini gr.  lxxv 

Aqua^  Destillata?     -        -        -        -  ,3  ijss 
Spts.  Lavandulae  Comp.     -        -       5  iJi 
Syr.  Limonis     -     -      -     q.  s.  ad     5  iv      M 
Sig.     One  dessert-spoonful  three  times  a  day. 

V^     Crofcon  Chlorali        -        -        -  3  i 

Glycerinje 

Syr.  Aurantise  -      -        -        -    aa  3  i     M 
Sig.     One  teaspoonful  per  dose. 

9;    01  Terebinthin^e  -        -        -        -      5  ii  —  Jii 
Mucilage  Accacise    -        -        -         q.  s. 
Ft.  Emulsio  et  adde 
Syr.  Zingeher       -        -        -        -     ,^  i 

Aquani ad  ^  iv     M 

Sig.     One  tablespoonful  every  four  to  six 

hours. 
.   .  Sciatica. 


31G  MANUAL  OF  NERVOUS  DISEASES. 

Neuralgia.      R     Strychnia^        -        -        -        -         gr.  «s 

Aqute   -        -        -        -        -        -      5  ss     M 

Sig.     Eight  drops  in  a  dessert-spoonful  of 
water  three  times  a  dav. 


Sciatica. 

5fe    Ext.  Nux  Vomicio        -        -        -     gr.  i 

Manme 9  i 

Ft.  massa  et  in  pil.  No.  viii  div. 
Sig.     One  pill  three  times  a  day. 

9?    Ammon.  Chloridi       -        -        -        5  ^j 
Ext.  Fl.  Glycyrrhiz?e    -        -        -     5  ss 
Syr.  Auranti?e    -        -        -        -        5  i 
Aqu?e      -        -        -        -        -    ad     g  vi    M 
Sig.     One  tablespoonful  three  times  a  day. 

Epilepsy.        9=    Potass.  Bromidi      -         -         -        5  ss 
Sig.     In  a  wineglassful  of  water. 

J^    Potass.  Bromidi       -        -        -  gr.  xv 

Sod;e  Bromidi 

Ammoniae  Bromidi      -        -         aa  gr.  v    M 
Sig.    In  a  tablespoonful  of  water. 

J^    Potass.  Bromidi      -        -        -        -    9  i 

Tinct.  Digitalis  -        -        -        gr.  v  —  x 

Elix.  Simplicis       -        -        -        -    5SS     M 

^    Potass.  Bromidi  -        -        -        -        9i 

Sol.  Fowleri    -        -        -        -      gtt.  iii       M 

9;    Potass.  Bromidi    -        -        -        -       9  i 

Tinct.  Belladonna'    -      -        -        gtt.  x      M 
Sig.     Three  times  a  day. 

9^     Sodas  Boracis        -        -  -        -     gr.  xv  —  xxx 
Glycerinae        -        -        -        -         gtt.  v 

Aqupe  Menth.  pip.         -  -        -    5  ss      M 
Sig.    Three  times  a  day. 


FORMULA.  317 

Nervine        V^    Spirt.  Aetheris  Comp. 
Stimulants.  Tinct.  Valeriana?  Ammon.       -     aa   5  i       M 

Sig.     One  teaspoonful  with  a  tablespoonful 
of  water. 

Hysteria. 

^     Spirt.  Ammon.  Aromat.    -        -  5  i 

Syr.  Aurantia*      -        -        -        -      5  ii     M 
Sig.     One  dessert  spoonful  every  hour. 

Nervousness. 

^    Spirt.  Vini  Gallici        -        -        -       ,^  ss 

Tinct.  Opii  Deodorat.       -        -     gtt.  xv  —  xxx  M 

Nervous  Shock. 

^    Aetheris  Chlor.  -        -        -        5  i 

Pulv.  Acaci?e    -      -        -        -  5  ss 

Aqure 5  iv    M 

Sig.     One  tablespoonful  every  two  hours. 

Hysteria. 

i*     Spirt.  Lavandulae  Comp. 

Tinct.  Cardamom.  Comp.  -  aa  5ss 
Syr.  Aurantia'   -        -        -  -       5  i       ^^ 

Sig.     One  dessert  spoonful  in  a  vvineglassful  of 
water. 

Restorative. 

J^     Cauiphont-  ....  g^-.  xxiv 

Sapo-medicat  -  -  -  -  q.  s 
M  et  divid  in  pillulas  -  -  viii 
Sig.     One  three  times  a  day. 

9=     Camphor^e        -        -        -        -         gr.  xxiv 
Aetheris  Sulph.    -        -        -        -     5  ss     M 
Sig.     Twenty  drops  in  a  wineglassful  of  water  every 
half  hour. 


318  MA N UAL  OF  NERVOUS  DISEASES. 

Nervine        ^    Ext.  Quebracho        -        -        -         .5  j 
StiMlantS.  Sig.    Twentj'  to  thirty  drops  three  times  a  day. 

Hysterical  Asthma. 

StiMlant     ^    Linimentum  Chloroformi        -  51" 
and  Sedative         Tinct.  lodini 

Applications.         Tinct.  Aconitii     -        -        -      aa  5  ii 

Tinct.  opii        ....  ggs    M 

9;    Methyl  Chloridi  pulv.     -        -        -Si 

Sig.     Apply  with  a  brush,  or  a  pledget  of  lint  to  tin 
painful  part. 


1^    Menthol      .        -        -        ■ 

gr.  iiss 

Cocaini  Muriatis    - 

-    gr.  viiss 

Chloral  Hydratis 

gr.  iv 

Vaselini 

-    5  ii^s    ^I 

Sig.  Apply  to  painful  part  and  cover  with  a  strip  of 
court-plaster. 

Supraorbital  Neuralgia. 

V^     Carbonis  Bisulphidi      -        -        -     o  i^' 
Pulv.  Camphora:*  q.  s.  ad  solut.  satur. 
Sig.     Apply  with  a  brush  to  the  painful  parts. 

Lxunho-ahdonii nal  Neuralgia. 


T^ 

01.  Terebinthinfi- 
Chloroformi 

-      5  viii  ss 

Tinct.  opii 

-    aa  5  ii  ^I 

Sci-xtica. 

Vc 

Ext.  Hyosciami 

Ext.  Balladonna? 

aa  5i 

Glycerinre 

-        -          5i    M 

Irritable  Testicle. 

9^    Methyl  chloridi 

Sig.     For  a  spray  to  the  vertel^ral  column. 

Spinal  Irritation.     (Huchard.) 


FORMULjE.  319 

Stimulant    V^    Atropifo  Sulphatis      -        -        -       gr-  v 
and  Sedative         Aquae  DestiU.  -        -        -  5  iii    M 

Applications.         pig.     Soak  a  compress  with   some  of  the  sohition 
and  apply  for  an  hour. 

Neuralgia    ( Trousseau). 

^    Ext.  Belladonn?e   -        -        -        -     5  i 
Tinct.  opii  .        -        .        -  §  i 

Glycerine^     -        -        -        -        -     §  iii     M 
Sig.  A  piece  of  Unt  wet  with  this  mixture  is  applied 

to  the  neuralgic  nerve.     Cover  the  part  with  oil 

silk. 

9;    Veratrise         -        -        -        -        -  gr.  xxiv 
Glycerinae   -        -        -        -        -       3  ii 
Spir.  Rectific  -        -        -        -   5  vi    M 

9;    Collodii  Cantharid.     -        -        -       5  iv 

Sig.     Paint  the  skin. 

liscellanBons. 

9    Magnesire  Sulphatis     -        -        -     5  iv 
Acidi  Sulphurici  dil.  -        -        5  i 

Ferri  Sulphatis      -        -        -        -    gr.  xv 
Syr.  Aurantife  .        -        -        -  ,^  ss 

Aqua?  Mentha?  pip.        -        -        -      5  vii    M 
Sig.    Two  tablespoonfuls  twice  daily. 

Tonic  Aperient. 

9    Ergotin  (Beaujou)      -        -        -        o  ss 

Ft.  pilhilas  no.  x. 
Sig.     One  ter.  in  die. 

9     Strychnia?       -         -        -        -         -     gr.  i 
Tinct.  Ferri  Chloridi         -        -  ,5  ^s 

Tinct  Colomb?e      -        -        -        "Hi 
Aqua?  -        -         -        -        -  ad     g  iv    M 

Sig.     One  teaspoonful  three  times  a  day. 

Nervous  Dyspepsia. 


320  MANUAL  OF  NERVOUS  DISEASES. 

MiSCellaneCUS.  ^  Tinct.  Digitalis  -  -  -  -  o  iss 
Ext.  Fl.  Ergoti  -  -  -  -  5  "SS 
Syr.  Aurantijc        -        -        -        -     .3  ss    M 

Sig.     One  teaspoonfnl  every  eight  hours. 

Essential  Vertigo. 

T^    Auro-Chloridi        -        -        -        -    gr.  i 
Ext.  Gentiani  -        -        -        -         gr.  xv 

Ft.  massa  et  in  pill,  No.  xxx  div. 
Sig.     One  three  times  a  day. 

Loco-motor  Ataxia. 

^    Acid  Arseniosi       -        -        -        -    gr.  i 
Mass.  Ferri  Carhonatis     -        -         3  i 
Quinise  S\ilpli.      -        -        -        -     3  s.s 

Ft.  massa  et  in  pill.    No.  xl  div. 
Sig.     One  pill  three  times  a  day. 

Nervous  Dyspepsia. 

1^    Hydrarg.  Chloridi   Corrosivi      -        gr.  i 

Glycerinje ,3  i 

Tinct.  Cinchon.  Comp.         -        -       ^  ii 
Spirt.  01.  Menthte  pip.     -        -      -   M  xxiv    M 
Sig.     One  teaspoonfnl  in  a  wineglassful  of 
water  ter.  in  die. 

Vertigo  'jfthe  aged. 

Meglin's  Pili.s. 

9;    Ext.  Hyosciami 

Zinc  Oxidi        -        -        -        -      aa    9ii      M 

Divide  into  forty  pills. 
Sig.     Eegin  with  one  pill  and  increase  by  one 
pill  every  other  day. 

Tic  doloreux. 


FORMULAE.  _i 

Miscellaneous.  Fournier's  pu,l.s. 

^    Zinci  Valerianae        -        -        .        -   gr.  v 
Ext.  Opii        .....      gr.'iss 
Ext.  Hyopciami        -        .        .        .  gj..  {[^^ 
Confect.  Ros;e      -        .        .        -       q.  s. 

Divide  into  six  pills, 
big.     One  pill  every  three  hours   until  three  are 
taken,   then  omit  the  pills,  and  take  them 
again  in  the  same  way  the  next  day. 

Neuralgia. 
Prof.  S.  Groj^s'  Pills. 
9^    Quinia?  Snlph.        .        -        .        -      Q  ii 
Morphine  Sul ph.        -        -        .  gj..  i 

Strychnine     -----        gr.  2^ 
Acid  Arseniosi        -        -        .        -      gr.  i 
Ext.  Aconitii       -        -        -        .         gr.  x 

Divide  into  twenty  pills. 
Sig.    Take  one  pill  three  or  four  times  a  day. 

Neiwalqia. 

Br0WX-Se(«ITARD'S    PfLLS. 

9^    Ext.  BelladonnjL-        -        -        .         or.  l- 
"     Stramonii        -         -        .  or. 

"     Cannabis  Iii(li(7ie    -        -        .      gr, 
''     Aconitii    -         .         .         . 
"     Opii     -        -        -        -        . 
"     Hyosciami  -        -        -     gr. 

''     Conii ar.  i 

Pulv.  Glycyrrhiza^         -         -        -       q.  s. 

Make  into  one  pill. 
Sig.     Take  from  three  to  four  pills  a  day. 
Brown  Sequard  has  observed  no  great  constitutional  disturbance 
from  the  use  of  these  pills  ( ?) 

„  Inveterate  Neuralgia. 


ffr.  i 


gr.  I 


GENERAL  INDEX. 


A 

Abscess  of  brain 248 

Abernethy 39 

A  C  C 00 

Aconite  in  nervous  diseases  .  .   51 

Aconitia  in  neuralgia 81 

Acute  hydrocephalus 195 

Agoraphobia 131 

Agraphia 218 

Akinesis 33 

Alexia 218 

Allochirea 29 

Amyotrophic  lateral  sclerosis  .  17<) 

Anwmia,  cerebral 222 

Anaesthesia 29 

"  in  hysteria 289 

Analgesia 29 

Analgia 29 

Andropliobia 131 

Anelectrotonus 60 

Angular  Gyrus 4 

Ankle  Clonus 47 

Anode 54 

Anstie 135 

A  0  C 60 

Apoplexy 223 

"         delayed 227 

ingravescent 227 

"         meningeal 194 

"         in  paretic  dementia  .304 


Aphasia 214 

"       amnesic 217 

"       ataxic 210 

Aphonia,  hysterical 289 

Aran igQ 

"Argyle  Robertson  symptom" 

162,  302 

Arkansas  Hot  Springs 152 

Arsenic  in  neuralgia 78 

Arthogryposis 271 

Ascending  current 69 

"         paralysis 153 

Ataxia,  loco-motor 159 

'*       hereditary ]  68 

\  Athetosis 268 

Atrophy,  hereditary 187 

' '      progressive  muscular .  1 79 
Auditory    symptoms  in    nerv- 
ous diseases 43 

Aur;e,  epileptic 275 

Aural  vertigo 283 

B 

Basilar  meningitis 190 

Bastian 231 

Beard,  George 127-132 

Belladonna  in  nervous  diseases   51 

Bibliography 309 

Blepharospasm 114 

Borborygnic'v  in  hj^steria 287 

( :!'23  ) 


32Jf 


GENERAL  IXDEX 


Bouchard 224 

Brachial  neuralgia 83 

Brain,  circulation  of 26 

Breast,  irritable 86 

"       amputation,  in  masto- 

dynia 86 

Brow  ache 78 

Brodie,  Sir  Benj 91 

BrownSequard 48,  151,  274 

Bulbar  paralysis 188 

Burdach's  column 23 

C 

Calabar  bean  in  nerv.  dis 52 

Capsule,  internal 17 

Castration  for  irritable  testicle  90 

Causalgia 84 

C  C  C 60 

Central  convolutions,  lesion  of  206 

Cephalalgia 122 

Cerebellum,  nerve  tracts  of. . .   20 

Cerebral  abscess 248 

"         anaemia 221 

"         breathing 44 

"         embolism 237 

''         hemorrhage 223 

"         hypertemia 221 

"    -   localization 206 

"        syphilis 252 

"         tumor 242 

"  "     varieties  of. . .  .252 

Cerebro  -  spinal    conducting 

paths 23 

Charcot. ..  168,  176,  180,  209,  211, 

224,  263 

"Cheyne-.Stokes"  breathing.  .   44 

"Choked  disk" 41 

"           "     in    cerebral 
tumor 244 


Chorea 

"      electric 

"Cincture  sensation" 

Circulation  of  brain 

Clarke 

Clarke's  column 

Claustraphobia 

"  Clavus  hystericus'" 

Clonus,  ankle 

Clubfoot  in  infantile  paralj'sis 

Coccygodenia 

Codeia  in  nervous  diseases. .  .  . 

Coma 

Combined  paralysis  of  arm. . . . 

Concussion  of  spinal  cord 

Conducting  power  of  tissues .  . 

I  Convolutions,  lateral 

"  of  frontal  lobe. 

I  "  occipital 

;  "  median 

I  "  parietal 

j  "  temporal 

i  Convulsions 

i  "  epileptiform 

!  "  hysterical 

"  infantile 

i    "Convulsive  tic" 

'  Contracture 

I  "  hysterical 

[   Corona  radiata 

I   Cortex,  the 

"  "  excitable  are  is  of. 

Corticle  centers 

I  Cramp. .    


263 

267 

45 

26 

180 

24 

131 

290 

47 

171 

90 

51 

38 

106 

155 

61 

1 

2 

6 
6 


'2S6 
"39 
113 

32 
289 

17 
9 

14 

14 


milkmaids' 

"      writers' 

"Crisis  gastrique"  in  ataxia 

"Croup,  false" 

Crural  nerve,  paralysis  of  .  . 


121 
119 
165 
115 
109 


GEXEEAL    INDEX 


Crusta •„ 20 

Cniveilhier 90 

Cuneus 8 


Da  Costa 267 

"  Dancing  ma.nia" 267 

Degeneration,  reaction  of 61 

Delirium 37 

Dementia,  paretic 299 

Density  of  electrical  currents.   58 

Descending  current 69 

Diagnosis,  electro 61 

Diet  in  nervous  diseases 49 

Diaphragm,  spasm  of 116 

Direction  method  in  electriza- 
tion      69 

Diseases  of  the  brain 221 

"         "  pia  mater 195 

"         "  peripheral  nerves.    73 
"         *'  membranes    of 

brain 193 

"         "  spinal  cord 144 

"        systemic,  of  cord  ....  159 

Disseminated  sclerosis 256 

Dorso-intercostal  neuralgia  ...  85 
Duchenne  .  .77,  106,  180,  188,  192 
Dura  mater,  hiematoma  of. .  .  .  193 

Duret 209 

Dyspepsia,  nervous 50,  292 

Dysphagia,  hysterical 289 

Dysmenorrhfea  in  hysteria  .  .  .  292 


Electricity,  medical 53 

'■  in  treatment   of 

neuralgia 76 

Electrical  examination 67 

Ellectric  bath 71 


Electric  chorea 267 

hand 271 

Electrotonus 60 

Electro-motive  force 57 

Electro-diagnosis 61 

Electro-therapy 67 

Electrization,  general  rules  for  71 

Elliotson 263 

Embolism,  cerebral 237 

Encejihalitis 248 

Endocardiac   murmur   in 

chorea 265 

Epilepsy 273 

cortical 280 

"        hystero- 287 

Jacksonian 39,  274 

reflex 274 

Epileptic  aurie 275 

Epileptogenous  zone 274 

Epileptoid  condition 278 

''  attacks   in    paretic 

dementia 304 

Equivalents  of  epilepsy 278 

Erb 61,  62,  106,  159,  187,  272 

"   juvenile   hereditary   atro- 
phy of 187 

Erythromelalgia 31 

Erichsen 156 

Esmarck. 91 

Essential  paralysis  of  children  169 
Eyeball,  spasm  of  muscle;  of.  112 

F 

Facial  spasm 113 

Faradism 55 

Faradic  brush 58 

Faradization,  general 71 

Ferrier 10,  11,  14 

Fissures,  lateral,  of  brain ....   1 


326 


G E NE RAL    I S D E X . 


Fissures,  inferior,  of  brain ....      8 
"         median,       "         ....     6 

Flechsig 24 

Formatio  reticularis 25 

Formuli^. . 311 

Fournier 159 

Friederich's  disease 168 

Friteh 10 

Friction  (massage) 72 


Gait,  spastic 175 

"      in  shaking  palsy 261 

Galvanism  in  nervous  diseases  54 

Galvanization,  general 70 

Ganglion  cells,  spinal 25 

Gastric  symptoms  in  nerv.  dis.   50 

Genu  of  internal  capsule 17 

Girdle  sensation ...  .45,  161 

"Globus  hystericus' 115,  287 

Glosso-labio- laryngeal    paral- 
ysis   188 

Glossy  fingers 84 

Gluteal  nerve,  paralysis  of . . .  .  107 

GoU's  column 23 

''  Grand  mal  " 276 

Griesinger 298 

Gyru.s  fornicatus 6 

"      hippocampi 7 

"      rectus 8 


H 


Hematoma  of  dura  mater.  ...  193 

Hammond,  Wm.  H 268 

Headache 36,  122 

Hemiplegia 32 

"  of  children 236 

Hemiaucesthesia 36 


Hemicrania 1 24 

Hemiparesis. 35 

Hemianopsia.' 42 

' '  test  for 42 

Hemorrhage,  cerebral 223 

"         of  spinal  meninges .  141 

Hereditary  ataxia 168 

"  atrophy  of  Erl>.  .  .187 

Herpes  Zoster  in  neuralgia .  79,  85 

Hiccough 116 

Hitzig 10,  13 

Horsley 14 

Hot  springs  of  Arkansas 152 

Hutchinson,  Johnathan 202 

Hydromyelia 155 

Hydrocephalus,  acute 195 

Hyosciamus  in  nerv.  dis 51 

Hyperalgia 28 

Hyperalgesia 28 

Hyperaesthesia 28 

hysterical 290 

Hyperkinesis 32 

Hj'per trophy,  pseudo 185 

"  lipomatous 185 

Hypenemia,  cerebral. 221 

Hypnotism 291 

Hypochondriasis 296 

Hysteria 284 

"  Hj'stericus,  globus" 287 

"  clavus" 290 

Hysterical  paralysis 288,  293 

"  aphonia 289 

' '  ana'sthesia 289 

dysphagia 289 

'*  ha-moptisis 292 

"  hypenesthesia 290 

"  hiomatemesis 292 

"          dysmenorrhtea  . . .  .292 
Hystero-epilepsy 287 


GENERAL   INDEX 


327 


I 

Incoordination  in  ataxia 165 

"  i  n'    p  a  r  e  t  i  c 

dementia 301 

Induction  current 55 

Inhibition 47 

Insomnia 37 

Infantile  spinal  paralysis 169 

Irritable  breast 86 

testicle 90 

Ischuria  in  hvsteria 292 


Lypomatous-hypertrophy  ....  185 

"  Living  skeleton" 182 

Localization,  cerebral 206 

Loco-motor  ataxia 159 

Local  spasm 112 

Lockhart-Clarke 180 

Lockjaw 112 

Lohmayer 216 


M 


Jacksonian  Epilepsy 274 

Joffroy 143,  176 

Juvenile  hereditary  atrophy .  .187 


K 


60 


KaSZ 

Kathode 54 

KCC 60 

Katelectrotonus 60 

Kennedy 172 

Knee  jerk 47 

Kussmaul 192,  216 


Labile  current 68 

Landry's  disease 152 

Laryngeal  crisis  in  ataxia.  . . .  165 

Laryngismus  stridulus 115 

Lateral  sclerosis,  primary.  . . .  174 
*'  "         amyotrophic.  176 

Lead  paralysis 109 

Leptomeningitis 139 

"  chronic  spinal..  141 

Leyden Ill,  258 

Lingual   spasm 115 


"  Main  en  griflfe" 106 

Mania  in  paretic  dementia.  . .  .304 
Masticatory  muscles,  spasm  of.  112 

Mastodynia 86 

Massage 74 

Measurement  of  electricity ...   58 
Medulla,  fibres  and  nuclei.  ...   21 

,   Meniere's  disease 37,  283 

^^iMelancholia     in     paretic    de- 
mentia   303 


Meningitis,  basilar 195 

I  "  of  convexity    .  .  .  .201 

metastatic 201 

j  "  spinal 139 

j  "  tubercular 195 

Meynert 20 

Migraine 124 

Milk-maid's  cramp 121 

Mitchell,  ^Yeir 

31,  49,  84,  90,  91,  134 

Monoplegia 33 

Moral  treatment  in  hypochon- 
driasis  29  < 

Motor   symptoms    in   nervous 

diseases 45 

Motor  points 63 

Multiple  sclerosis 256 

Muscle,    pseudo    hypertrophy 
of ,.185 


3es 


GENERAL  INDEX 


Muscle,     lypomatous     hyper- 
trophy of 185 

Muscular  atrophy,  progressive.  179 

Muscular  sense ....'. 30 

Munk 14 

Myelia 155 

Myelitis 146 

"       cervical 150 

"       dorsal 150 

"       lumbar 151 

"       microscopic     appear- 
ance in 1 47 

"       transverse 150 

Myotonia,  congenital 272 

Mysopholjia 131 

N 

Neftel '. .   80 

Neck,  v\ry 117 

Nerve  fibres  in  bram,  system  of  15 

"      associative 15 

"         "      commissural 16 

"         "      radiating 17 

*'      stretching 78 

Nervousness 40 

Nervous  dyspepsia 292 

Neurasthenia 127 

Neurectomy 78 

Neuralgia 10 

Neuromata 96 

Neuritis 92 

"      alcoholic 95 

"       interstitial 92 

"       multiple  .  . . .  94 

' '       nodosa 94 

"       optic 41 

"       pathology  of 92 

Neuralgia,   general  considera- 
tion of 73 


Neuralgia,  crural 

87 

"          anno-peronialis.  .  . 

90 

"          different  forms  of. 

78 

"          diagnosis  of 

80 

"          brachial 

83 

"          epileptiform 

74 

"          exciting  causes  of. 

74 

"          dorso-intercostal. . 

85 

"          general  treatment. 

76 

"          lumbar 

87 

"          obturator 

87 

"          of  the  genitals 

90 

"          of  the  joints 

91 

'*          prognosis  of 

80 

occipital 82 

predisposing  causes 

of 73 

reflex 74 

symptomatology  of.   75 

sciatic 87 

spermatic 90 

trigeminal 78 

vaso-motor     symp- 
toms     S3 

Neuroses,  professional 119 

Nictitating  spasm 114 

Nothnagel 208,  280 

Nystagmus 112 

"         in  multiple  sclerosis.  257 


Obturator  nerve,  paralysis  of..  107 

CEsophagus,  spasm  of 113 

Ohm's  law 57 

Opium  in  nervous  diseases.. .  .   50 


Pacchy meningitis  spinalis. ...  138 
"  cervical  is  .  .  142 


G E NE RAL   IND E X 


3r?9 


Paecliy  meningitis,     internal 

hemorrhagic 193 

Painful  tubercle 96 

Palsy,  wasting 179 

"      shaking 260 

Paresthesia 30 

Paralgia 30 

Paraldehyde  in  hysteria 295 

Paralysis 83 

"         alternate-crossed. 33,  213 

"         atrophic 34 

"         arsenical 110 

"         acute  ascending 153 

"         agitans 260 

"         bulbar 188 

"         combined,  of  arm.  .  .106 

"         diphtheric 110 

facial 99 

' '         functional 34 

lead 109 

"         musculo  spiral 104 

"         of  ocular  muscles. ...   41 
'■'         of    motor   branch    of 

trigeminus 98 

"         of  sterno  cleido  mas- 
toid  102 

"         of  pectoralis 103 

"         of  latissimus  dorsi.  .  .  103 
"         of  rotators  of  hume- 
rus  103 

"         of  serratus  magnus .  .103 

of  deltoid 104 

"         of    biceps    and   l)rac- 

liialis  anticus 104 

"         of  leg  muscles 107 

' '         of  crural  nerve 1 07 

' '         of  obturator  nerve .  . .  1 07 

"         of  gluteal  nerve 107 

"         of  peroneal  nerve. .  .108 


Paralysis  of  tibial  nerve 108 

"  of  sciatic  nerve 108 

"  peripheral 97 

in  hysteria 288 

reflex   Ill 

"  of  rhomboidii  and 

levator  scapuhe. .  103 
"         spinal,  from  growths.  155 

"         spastic 34 

"         of  trapezius 102 

"         essential,  of  children.  169 

Paraplegia 34,  45 

Paresis 32 

Paresthesia 30 

Paraphasia 217 

Paretic  Dementia 299 

Pathophobia 131 

Perimeter < 42 

Peripheral  nerves,  diseases  of. .    73 

Peripheral  paralysis 97 

Peroneal  nerve,  paralysis  of.  .  108 

"Petit  mal" 277 

"Phantom  tumor  " 292 

Pia  mater,  diseases  of 195 

Physostigma  in  nerv.  dis 52 

Polyesthesia 29 

Polar  action  of  electricity ....    59 

"Points  apophysaire" 45 

Points,  painful 75 

Poliomyelitis  anterior 1 69 

"  in  adults 173 

Potential,  electric 54 

Propulsion  in  shaking  palsy.  .261 

Primary  lateral  sclerosis 174 

Progressive  muscular  atrophy.  179 

Primar}^  current 56 

Psuedo-hypertrophy 185 

Psychical  blindness 15 

' '         deafness 15 


S30 


G  E  X  E  RAL   I  iV  D  E  X 


Psycho-motor  centers 15 

Puncta  dolorosa 75 

Pupil  in  nerv.  dis 40 

"     Argj'Ie-Robertson 42 

"            ''               "         in  pa- 
retic dementia 302 

Pyramidal  tract 18 

R 

Railwaj^  spine 155 

Reaction  of  degeneration (32 

Reflex  action 46 

'"     tests  for 46 

"      cremaster 46 

"      epigastric 46 

"      epilepsy 274 

"      plantar 46 

"      gluteal 46 

' '      patellar 47 

"'      movements  in  neuralgia  79 

"      in  ataxia 164 

Reil,  island  of 1 

Respiratory     muscles,    spasm 

of 115 

Rest  in  nerv.  dis 49 

Retropulsion    in   shaking 

palsy 261 

Reynolds,  Russell 151,  263 

R.  D 62 

"Risus  sardonicus" 114 

Rindfleisch 258 

Rolando,  Assure  of 1 

"        gelatin  oils  substance 

of 24 

Rolandic  region 4 

Romberg's  symptom  in  ataxia.  .163 

Ross 143,  186 

Rules    for   the   application   of 
electricity^ 71 


S 

Sayre,  Dr 168 

Sclerosis  of  the  brain 256 

"       disseminated 256 

"       primary  lateral 174 

"       amyotrophic  lateral . .  176 

Sclerose  en-plaque 256 

Sciatic  nerve,  paralysis  of ... .  108 

Sciatica 87 

"       diiferential  diagnosis. .   88 

"       rheumatic 89 

Secondary  current 56 

Seguin 216 

Sensory  crossway 24 

Sensory  paths  of  spinal  cord. .   26 
Sexual    function,    impairment 
of  in  nervous  diseases.  ...    46 

Shaefer 14 

Shaking  palsy 260 

Sick  headache 124 

Singultus 116 

Softening  of  the  brain. .  .  237,  299 

Somnolence 38 

Spasm 32 

"      local 112 

"      saltatory 119 

'*      of  masticatory  muscles.  112 

"      facial 113 

"      nictitating 114 

"      lingual 115 

' '      of  esophagus 115 

"      of  respiratory  muscles.  .115 

' '      diaphragm 115 

"      of  muscles  of  neck 115 

"      bilateral  clonic 117 

"      of  muscles  of  arm 118 

"      carpo-pedal 38 

Spastic  spinal  paralysis    ....    174 


GENERAL  INDEX 


331 


Spastic  gait 175 

(Spermatic  neuralgia 90 

Special  senses,  effect  of   elec- 
tricity on 61 

.Sphincters,  affection  of 46 

Spider  cells,  in  myelitis 147 

Spinal  cord,  concussion  of . ...  155 
"  paralysis,  infantile. ...  169 
"       symptoms    in    nervous 

diseases 144 

''       irritation 45,135 

**       paralysis,  spastic 174 

'*       apoplexy 141 

"       leptomeningitis,  chronicl41 
''       meninges,    hemorrhage 

.    of 141 

•'       meningitis 139 

' '      pacchy  meningitis 1 38 

*  •       paralysis,  from  growths 

in  cord 155 

Springs,  Arkansas  hot 152 

Stabile  current 68 

Stigmata  in  hysteria '292 

Stramonium  in  nerv.  dis 51 

Striimpel 236 

Strychnia  in  neuralgia 78 

St.  Vitus'  dance 263 

Suspension  in  ataxia 167 

Symbols  of  polar  action  ....  59,  60 
Symptomatology  of  nerv.  dis. .  28 

Sylvius,  fissure  of 1 

Syphilis  and  ataxia. .    159 

' '        of  brain 252 

System  of  nerve  fibres  in  brain  15 

Systemic  diseases 144 

Syringo-myelia 155 

T 

Tabes  dorsalis 159 

"      dorsal  spasmodique  . . . .  174 


\  Tache  cerebral 44 

j  Tapotement 74 

t  Tarantism 267 

I  Talipes  calcaneus 108 

Tegementum 20 

Tendon  Reflex  in  ataxia 164 

Testicle,  irritable 90 

Tetany 269 

Theories  of  motor  phenomena.   13 

Therapeutics  of  nerv.  dis 49 

Thomsen's  disease 272 

Thrombosis  cerebral 237 

"  of  cerebral  sinuses.  143 

Tibial  nerve,  paralysis  of 108 

Tic  convulsive 113 

Tic  doloreux 79 

:   "Torticollis  spastica" 117 

Tremor 32 

Trophic  cells .      26 

"        disturbances 32 

"        changes  in  neuralgia..  76 

Trigeminus,  neuralgia  of 78 

Trousseau 192,269,278 

Trousseau's  sign  in  Tetany.  .  .271 

Tubercle,  painful 96 

Tubercular  meningitis 195 

Tumor,  phantom,  in  hysteria. 292 
Turk 24 


Turk's  cohimn. 


23 


Ulnar  paralysis 105 

Uncus 7 

Unilateral  lesion  of  the  cord.  .155 


Vaso-motor  centers 31 

"        "      disturbances 30 

Vertigo 36 


33S 


G EXE U A L   IX D EX . 


Vertigo,  aural 283 

"       essential 36 

Vomiting,  cerebral 38 

A'oltaic  alternatives 68 

W 

Wasting  palsy 179 

Word  deafness ! .  217 

Vrrist  drop 105 

"         "in  lead  paralysis.  .  109 


Writer's  cramp 119 

Wry  neck 117 


Young 145 


Ziemssen 62 

Zone,  motor 11 


ERRATA. 

Page  26 — 4th  line  from  top,  for  "  nerves"  read  cornua. 

Page  180 — *'  Lockhart  Clarke"  (one'name). 

Page  209— 3d  line  from  top,  for  "  heniianospia"  read  lieuiianopsia. 

Page  310 — 7th  line  from  top,  for  "  Tros.';eau"jead  Trousseau. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

/  Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-30m-7,'56(C824s4)444 


UNIVERSITY  Of  CALIPu... 
AT 
L03  ANGELES 
LIBRARY 


